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Obstetric  Surgery. 


EGBERT  H.  GRANDIN,  M.D., 

Obstetric  Surgeon  to  the  New  York  Maternity  Hospital;    Gynaecologist  to  the 
French  Hospital,  etc.  ; 


GEORGE  W.  JARMAN,  M.D., 

Obstetric  Surgeon  to  the  New  York  Maternity  Hospital  ;    Gynaecologist  to  the 
Cancer  Hospital,  etc. 


With  Eighty=Five    Illustrations  in  the  Text  and  Fifteen    Photo= 

graphic  Plates. 


'Or, 


^ 


PHILADELPHIA  : 

THE   F.  A.  DAVIS   COMPANY,  PUBLISHERS. 

LONDON : 

F.  J.  PvEBMAK 

1894. 


COPYRIGHT,  1394, 

BY 

THE  F.  A.  DAVIS  COMPANY. 
[Registered  at  Stationers'  Hall,  London,  England.] 


Philadelphia,  Pa.,  U.S.A.: 

The  Medical  Bulletin  Printing-House, 

1916  Cherry  Street. 


PREFACE. 


The  key-note  of  this  volume  is  election  in  obstetric 
surgery. 

The  results  which  are  daily  secured  in  general  surgery 
through  resort  to  timely  operation  are  obtainable  in  obstetrics 
if  the  same  principle  be  held  in  view. 

This  volume,  further,  being  Avritten  from  a  teaching  basis, 
is  necessarily  imbued  with  the  personality  of  the  authors,  and 
is,  therefore,  not  burdened  with  literature  references  and  sta- 
tistical data.  The  latter  have  alone  been  introduced,  when 
necessary,  in  order  to  assist  in  the  elucidation  of  some  disputed 
point. 

The  illustrations  have  been  prepared  and  selected  with  the 
special  end  in  view  of  teaching  graphically.  The  works  of 
Barnes,  Charpentier,  Lusk,  Cazeaux,  and  Oscar  Schaeffer,  in 
particular,  have  furnished  many  of  the  wood-cuts,  and  the 
authors  hereby  express  their  obligation.  The  photographic 
plates  have  been  prepared  from  nature  under  the  personal 
supervision  of  the  authors. 

On  the  basis  of  honest  desire  to  promote  progress  in 
obstetrics,  this  volume  is  offered  to  the  medical  profession. 

September,  189J:. 


(iii) 


CONTENTS. 


INTRODUCTION. 

PAGE 

Obstetric  Asepsis  and  Antisepsis, 1 

CHAPTER  I. 
Obstetric  Dystocia  and  its  Determination, 9 

CHAPTER  II. 

Artificial  Abortion  and  the  Induction  of  Premature  Labor,      .       34 

CHAPTER  III. 

The  Forceps, .        .         12 

CHAPTER  lY. 
Yersion, 93 

CHAPTER  Y. 

Symphysiotomy, .        .         .120 

CHAPTER  YI. 

The  Cesarean  Section,  ,         .        .        .         .        .        .         .132 

CHAPTER  YII. 
Embryotomy,    .  146 

CHAPTER  YIII. 

The  Surgery  of  the  Puerperium, 163 

CHAPTER  IX. 
Ectopic  Gestation, 193 


Index,      ...........  203 

(V) 


LIST  OF  ILLUSTRATIONS. 


FIG.  PA&E 

1.  Normal  female  pelvis, 9 

2.  Beaudelocque's  pelvimeter, 10 

3.  Martin's  pelvimeter,      .............  10 

4.  Schultze's  pelvimeter, .11 

5.  CoUyer's  pocket  pelvimeter, 11 

6.  Justo-major  pelvis, 18 

7.  Generally  equally  contracted  pelvis  (justo-minor), 19 

8.  Flat  non-rachitic  pelvis, 20 

9.  Flat  rachitic  pelvis  (mild  grade), 21 

10.  Flat  rachitic  pelvis  (high  grade), 22 

11.  Generally  contracted  flat  rachitic  pelvis, 23 

12.  Roberts's  pelvis.     The  transversely  contracted  pelvis, 24 

13.  The  kyphotic  pelvis,  showing  narrowing  in  the  transverse  diameter  and  length- 

ening in  the  conjugate, 25 

14.  Non-rachitic  scoliotic  skeleton, 26 

15.  Rachitic  scoliotic  skeleton,            ...........  26 

16.  Spondylolisthetic  pelvis, 27 

17.  The  osteomalacic  pelvis, 29 

18.  Obliquely  distorted  pelvis  of  Naegele, 80 

19.  Osteosarcoma  of  the  pelvis, 32 

20.  Steel-branched  dilator, 41 

21.  Uterine  curette, 41 

22.  Ovum  forceps, 42 

23.  Glass  irilgating  tube, 42 

24.  Fi-itsch-Bozeman  catheter,    ............  42 

25.  Edebohl's  speculum, 43 

26.  Cervical  tenaculum,      .         .         .         . 43 

27.  Intra-uterine  dressing  forceps, .45 

28.  Barnes's  bags,        •■•...........  66 

29.  McLean's  bag,       ..............  66 

30.  Marx's  incubator  (closed), 70 

31.  Marx's  incubator  (open), 71 

32.  Elliott  forceps, 72 

3.S.  Hunter  forceps, 73 

34.  Lusk-Tarnier  forceps, 73 

35.  Jewett's  axis-traction  forceps,       ...........  74 

36.  Showing  Reynolds's  traction  rods  in  position, 75 

37.  Introduction  of  the  left  blade  of  the  forceps, 79 

38.  The  left  blade  introduced  ;  the  right  blade  (in  outline)  ready  to  be  introduced,        .  80 

39.  The  forceps  adjusted  and  ready  to  be  locked, 81 

40.  Showing  the  direction  of  the  line  of  traction, .  83 

41.  Showing  direction  of  traction  in  face  presentation,     .         .         .  '      .         .         .         .86 

42.  Tarnier  forceps  applied  to  the  thighs, 88 

43.  Incision  of  the  cervix,           ............  89 

44.  Application  of  medium  forceps, 90 

(Vii) 


viii  LIST    OF   ILLUSTRATIONS. 

FIG.  PAGE 

45.  First  stage  of  bipolar  version, 102 

46.  Grasping  the  knee, 103 

47.  Representing  first  act  of  extraction, ^04 

48.  Version  in  head  presentation, 106 

49.  Completing  the  version, 107 

50.  Impacted  shoulder, 108 

51.  Introduction  of  the  left  hand  to  bring  down  the  posterior  (left)  leg,       .         .         .  109 

52.  Showing  direction  of  traction, 110 

53.  Method  of  releasing  the  cord, Ill 

54.  Disengagement  of  the  posterior  (right)  arm, 112 

55.  Showing  direction  of  traction, 113 

56.  The  child  is  lifted  over  the  perineum  and  the  occiput  passes  from  under  the  sym- 

physis,            114 

57.  Chin  arrested  at  symphysis, 115 

58.  Forceps  applied  to  after-coming  head, 116 

59.  The  bulging  of  peritoneum  and  of  bladder  into  the  opening  at  the  joint,        .         .  133 

60.  Galbiati-Harris  Knife.     (Harris's  modification), 124 

61.  Showing  deep  suture  passed,  the  loops  not  cut, 138 

62.  The  same,  the  loops  cut, 138 

63.  Suture  of  uterine  wound, 139 

64.  Braun's  trephine, 148 

65.  Blot's  perforator, " .         .148 

66.  Martin's  trephine, 1*9 

67.  Scissors-perforator, l*^ 

68.  Braun's  cranioclast, 149 

69.  Effect  of  the  cranioclast  on  the  foetal  skull, 151 

70.  Lusk's  cephalotribe, 154 

71.  Tarnier's  basiotribe, 1'54 

72.  Bone-forceps, •  ^^'^ 

73.  Crochet  and  blunt  hook, 157 

74.  Braun's  hook  or  decollator, 15° 

75.  Delivery  of  trunk  after  section  of  head, 159 

76.  Locked  twins, 160 

77.  Sutures  inserted  on  one  side  of  a  lacerated  cervix, 166 

78.  Insertion  of  sutures.     (After  Hegar.), 1*^1 

79.  Laceration  through  the  sphincter.     Sphincter  sutures  in  place,        .         .        .         .172 

80.  Repair  of  a  vesico-vaginal  fistula, l'''^ 

81.  Simon's  specula, '         .         .         .  175 

82.  Transverse  rupture  of  the  uterus, l'^9 

83.  Cleveland's  ligature-carrier, 1"''' 

84.  Emergency  Trendelenburg  posture, 198 


LIST   OF   FULL-PAGE    PLATES. 


PAGE 

Plate  I. — Measurement  of  distance  between  the  spines,    .         .         .         .12 

Plate  II. — Fig.  1.  Measurement  of  Beaudelocque  diameter.  Fig.  3. 
Measurement  of  Beaudelocque  diameter  in  case  of  pendulous 
abdomen, 13 

Plate  III.— Fig.  1.  Determination  of  the  diagonal  conjugate.  Fig.  2. 
Depression  of  the  uterus  so  as  to  determine  adaptability  of  pre- 
senting part  to  the  pelvic  brim, 14 

Plate  IV. — Introduction  of  the  left  blade  of  the  forceps,  ...      79 

Plate  V. — Fig.  1.  Towel  applied  to  handle  of  Hunter's  forceps.     Fig.  2. 

Bilateral  incision  of  the  perineum  (episiotomy),  ....      83 

Plate  VI. — Showing  method  of  grasping  the  foot, 109 

Plate  VII. — Extracting  the  posterior  leg, 109 

Plate  VIII. — Extracting  the  posterior  arm,       .         .         .         .         .         .     113 

Plate  IX. — Head  impacted  at  the  outlet.     Admitting  air  that  the  child 

may  breathe, 115 

Plate  X. — The  child  is  lifted  over  the  perineum  and  the  occiput  passes 
from  under  the  symphysis.  An  assistant  makes  suprapubic 
pressure, 115 

Plate  XI. — Traction  while  the  head  is  in  the  ti-ansverse  diameter  of  the 

pelvis, 116 

Plate  XII. — Application  of  the  forceps  to  the  after-coming  head,    .         .     116 

Plate  XIII. — Method  of  grasping  the  child's  body  in  performing  in- 
ternal rotation, US 

Plate  XIV. — Fig.  1.  Trephining  the  before-coming  head.  Fig.  2.  Per- 
foration of  the  after-coming  head,  .         .         .         .         .         .     150 

Plate  XV. — Insertion  of  Braun's  decollator, 158 


(ix) 


Obstetric  Surgery. 


INTRODUCTION. 
OBSTETRIC    ASEPSIS   AND   ANTISEPSIS. 

It  is  only  within  the  last  decade  that  obstetric  surgery  has 
progressed  toward  the  scientific  eminence  to  which  it  may  justly 
lay  claim  to-day.  Before  the  advent  of  tlie  era  of  antisepsis 
and  asepsis,  before  the  fear  of  handling  the  uterus  had  been 
swept  away,  the  forceps  and  version  were  the  only  operations 
which  came  within  the  ken  of  the  average  practitioner,  and  the 
results  from  resort  to  these  were  anything  than  matters  to  be 
proud  of.  So-called  childbed  fever  was  virulent  not  alone  after 
spontaneous  labor  at  term,  but  also  after  resort  to  any  and  all 
obstetric  operations. 

To-day  the  scene  has  radically  changed.  Septicaemia  after 
labor  is  justly  considered  as  due,  in  almost  every  instance,  to 
faulty  asepsis ;  gradually  bettering  attempts  are  being  made  to 
educate  the  student  with  a  practical  knowledge  of  the  entire 
range  of  obstetric  surgery,  and  extra  stress  is  being  laid,  as  it 
should  be,  on  the  absolute  necessity  of  studying  the  pelvis  of 
the  pregnant  woman  before  the  advent  of  labor,  so  as  to  be  in 
a  position  to  take  advantage  of  that  operative  procedure,  where 
any  is  indicated,  which  is  best  not  alone  for  the  woman,  but 
which  also  takes  into  account  the  welfare  of  the  child.  Whilst, 
then,  more  accurate  educational  methods  enter  as  factors  in  the 
science  of  obstetrics  as  practiced  to-day,  the  fundamental  reason 
why  mortality  rate  has  been  lowered  is  the  recognition  of  the 
culpability  of  the   man   who   neglects   the  laws   of  cleanliness 

(1) 


*2  OBSTETRIC     SURGERY. 

(asepsis  and  antisepsis)  thronghout  the  conduct  of  labor  and 
during-  the  puerperal  state.  Lack  of  cleanliness  (asepsis  and 
antisepsis)  will  ruin  the  most  expert  technique,  and.  therefore,  a 
thorouo-h  oroundmo'  in  the  fundamental  laws  of  cleanliness  as 
applied  to  obstetric  work  is  essential  to  the  undertaking  of  any 
of  the  surgery  of  the  art. 

Antisepsis  is  simply  the  means  of  certifyins:  to  asepsis 
(cleanhness).  The  whole  question  has  been  needlessly  compli- 
cated by  the  introduction  of  scores  of  chemical  agents  which 
possess,  to  a  greater  or  less  degree,  the  power  of  rendering  inert 
the  micro-organisms  which  exist  in.  or  may  be  conveyed  to,  the 
human  body.  It  is  possible  to  secure  asepsis  without  resorting 
to  antisepsis,  but.  in  order  to  surround  surgery  with  every  possible 
safeguard,  these  chemical  agents  must  be  looked  upon  as  abso- 
lutely essential,  The  point  to  be  remembered  in  obstetiic  surgery 
is  that  too  free  indulgence  in  antisepsis  may  do  harm  even  whilst 
it  aims  at  good.  The  nature  of  many  of  the  antiseptic  agents 
on  which  we  must  needs  rely  is  poisonous  to  the  human  body. 
Therefore  the  corollary  must  be  borne  in  mind  that  overzealous- 
ness  in  matters  of  antisepsis  may  injure  and  kill,  even  as  lack  of 
asepsis  may  be  followed  by  similar  effects.  Obstetric  asepsis  is 
secured  through  attention  to  (a)  the  person  of  the  accoucheur, 
the  nurse,  and  assistants;  (b)  the  lying-in  woman;  (c)  the 
instruments  and  accessories. 

('-0  Asepsis  of  the  Accoucheur  axd  Attexdaxts. 

It  being  absolutely  proven  that  septiceemia  is  heterogenetic, 
— that  is  to  say,  does  not  originate  within  the  body. — it  is  the 
bounden  duty  of  all  who  come  in  direct  contact  with  the  lyhig-in 
woman  to  keep  themselves  not  alone  clean,  but  also  free  from 
those  acute  infectious  elements  which,  through  inoculation,  breed 
sepsis.  The  ideal  obstetrician,  like  the  ideal  surgeon,  should 
avoid  seeing  patients  suffering  from  certain  of  the  acute  infec- 
tious diseases,  such  as  scarlet  fever  and  diphtheria  ;  and.  except 
in  absolute  emergency,  should  have  nothing  to  do  with  post- 


OBSTETRIC   ASEPSIS   AND    ANTISEPSIS.  3 

mortem  examinations.  These  rules  of  conduct  should  be  abso- 
lute with  the  expert  obstetrician,  wlio,  from  recognized  standing, 
is  liable  at  any  time  to  be  called  upon  to  give  advice  in  the 
minor  emergencies  of  labor  or  to  act  as  chief  in  major  operative 
obstetrics.  Barring  spontaneous  or  operative  traumatic  lesions, 
the  risk  the  lying-in  woman  runs  is  septic  infection  at  the 
hands  of  her  immediate  attendants.  The  general  practitioner 
of  necessity  must  perform  obstetric  work  even  whilst  his  routine 
duty  calls  for  attendance  on  scarlet  fever,  for  instance.  The 
greater,  therefore,  the  precautions  he  should  take  to  bathe 
thoroughly,  to  change  his  garments,  to  wash  his  hair  and 
beard,  to  asepticize  his  hands  before  going  from  such  diseased 
states  to  a  woman  who  is  about  to  perform  a  physiological  act. 
In  the  event  of  his  time  being  occupied  to  a  great  degree  with 
attention  to  patients  sick  from  any  of  the  acute  infectious  dis- 
eases, so  that  he  finds  it  difficult  to  take  the  simple  and  yet 
most  essential  precautions  mentioned  above,  then  it  is  wise,  to 
say  no  more,  for  the  time  being  to  refuse  to  attend  labor  cases, 
else,  as  has  too  frequently  happened,  one  puerpera  after  another 
will  be  diseased,  if  not  killed.  Tlie  man  who  makes  post-mortems 
frequently  is  a  death-dealing  obstetrician,  and  the  careless  gen- 
eral practitioner  may  become  such.  It  has  been  well  said,  and 
cannot  be  emphasized  too  strongly,  that  puerperal  sepsis  means 
faulty  technique, — that  is  to  say,  one  or  more  of  the  attendants 
are  to  blame.  There  is  no  shifting  the  responsibility  on  nature. 
Sucli  general  measures  as  have  been  noted  apply  with  even 
greater  force  to  the  nurse.  She  will  come  more  frequently  in 
contact  with  the  woman,  and,  if  careless,  is  even  more  likely  to 
septicize.  If  ignorant,  as  outside  of  large  centres  she  is  apt  to 
be,  she  may  even  now,  in  this  aseptic  age,  fill  grave-yards  as 
she  did  in  the  past.  It  becomes,  therefore,  the  duty  of  the 
physician  to  investigate  the  previous  occupation  and  where- 
abouts of  the  nurse  his  patient  has  engaged,  and  to  insist  on  her 
practicing  the  most  rigorous  antisepsis  as  regards  her  clothing 
and  person.     Asepsis  is  not  sufficient  for  the  average  nurse  ;  she 


4  OBSTETRIC     SURGERY. 

must  be  provided  with  antiseptics  in  order  to  cause  her  to 
approximate  cleanhness.  It  goes  without  saying-  that  she  should 
never  be  allowed  to  attend  the  lying-in  woman  if  she  has  been, 
"vvithin  at  least  a  week,  in  attendance  on  one  of  the  acute  infec- 
tious diseases.  The  rigid  rules  about  to  be  noted  as  applicable 
to  the  care  of  the  obstetric  hands  are  to  be  enforced  with  her 
even  as  they  must  be  with  the  physician. 

In  the  lying-in  room  the  physician  should  remove  his  coat 
and  roll  up  his  shirt-sleeves  above  the  elbow.  Since,  aside  from 
instruments,  the  hands  are  most  likely  to  septicize  the  woman 
from  direct  contact,  great  care  must  be  exercised  to  render  them 
aseptic.  If  the  physician  has  recently  been  in  contact  with  any 
infectious  material,  thorough  washing  in  soap  and  water  and 
scrubbinof  in  bichloride  solution  will  not  suffice  to  render  these 
hands  aseptic.  Under  such  conditions  the  following  method 
must  be  resorted  to  :  The  hands  and  arms  are  scrubbed  for  at 
least  ten  minutes  in  hot  soap  and  water,  the  latter  being  fre- 
quently changed.  Especial  attention  must  be  paid  to  the  finger- 
nails, under  which  the  infectious  elements  are  most  prone  to 
lodge.  The  hands  and  the  arms  are  next  covered  with  a  hot 
saturated  solution  of  permanganate  of  potash,  and  are  then 
immersed  in  a  hot  saturated  solution  of  oxalic  acid  until  the 
stain  of  the  permanganate  has  entirely  disappeared.  The 
oxalic  acid  is  next  removed  by  soaking  the  hands  in  hot 
sterilized  water. 

If  the  physician  be  at  all  suspicious  about  the  nurse,  she 
should  be  compelled  to  resort  to  the  same  process  under  his 
direct  supervision.  It  has  been  proven  by*  culture  experiments 
that  this  method  of  treating  the  hands  renders  them  absolutely 
free  from  micro-organisms. 

Under  ordinary  conditions,  where  the  physician  is  sure  of 
his  freedom  from  infectious  material,  this  elaborate  process  is  not 
necessary.  It  will  suffice  to  scrub  the  hands  in  hot  soap  and 
water,  and  next  to  immerse  them  in  a  1  to  1000  solution  of 
bichloride  of  mercury.    They  are  then  washed  in  alcohol.     After 


OBSTETRIC   ASEPSIS   AND    ANTISEPSIS.  O 

this  sterilization  of  the  hands  the  physician  must  avoid  touching 
anything  which  has  not  been  similarly  sterilized. 

Before  proceeding  to  the  performance  of  any  obstetric 
manipulation,  the  physician  should  cover  his  clothing  with  a 
clean  sheet,  which  may  be  found  in  even  the  households  of  the 
most  indigent. 

(b)  Asepsis  of  the  Lying-in  Woman. 

Thorough  asepsis  of  the  genital  tract  of  the  woman  is  most 
essential,  and,  at  the  same  time,  most  difficult  to  secure.  These 
organs  must  be  rendered  surgically  clean,  and  yet  the  means 
resorted  to  must  be  such  as  will  not  injure  the  protecting  coat 
of  epithelium.  It  is  very  questionable  if  douching  of  the  geni- 
tals is  sufficient  for  asepsis.  The  antiseptic  agents  thus  em- 
ployed at  best  only  come  in  contact  with  the  superficies.  The 
vagina,  in  particular,  is  rendered  aseptic  with  difficulty.  It  is 
in  the  depths  of  the  rugosities  that  the  micro-organisms  lodge. 
Before  undertaking  any  surgical  manipulation  the  following 
means  should  be  resorted  to :  The  external  genitals  are  to  be 
scrubbed  with  hot  soap  and  water,  and  next  washed  with  a 
solution  of  bichloride  (1  to  1000).  If  the  required  manipu- 
lations are  in  the  vagina,  a  new  tooth-brush  should  be  inserted 
into  the  canal,  and  this  should  also  be  scrubbed  with  soap  and 
water.  It  is  next  to  be  scrubbed  with  a  solution  of  bichloride 
of  mercury  (1  to  1000). 

In  the  event  of  the  proposed  operation  being  a  symphysi- 
otomy or  a  Caesarean  section,  the  pubes  must  be  shaved,  the 
skin  thoroughly  washed  with  soap  and  water,  then  washed  with 
bichloride  solution  (1  to  1000),  and  finally  with  alcohol  or  with 
ether.  After  any  manipulation  in  the  uterus,  in  order  to  certify 
to  perfect  post-operative  technique,  the  entire  genital  tract 
should  be  douched  with  bichloride  solution  (1  to  5000).  There 
is  risk  of  poisoning  if  sti'onger  solutions  than  this  are  used  in 
the  uterus. 


6  OBSTETRIC     SURGERY. 

(c)  Asepsis  of  Instruments  and  Accessories. 

The  elaborate  processes  wliich  are  in  use  in  hospitals  obvi- 
ously cannot  be  resorted  to  in  private  practice.  Just  as  thorough 
asepsis,  however,  as  regards  instruments,  may  be  secured  if  these 
instruments  have  been  carefully  cleansed  by  the  physician  before 
they  are  taken  to  the  woman's  house.  Instruments  which  have 
been  scrubbed  with  soap  and  water,  and  next  boiled  for  ten 
minutes  in  a  1-per-cent.  solution  of  carbonate  of  soda  (the  com- 
mon washing-soda),  may  be  deemed  aseptic.  This  asepticism, 
however,  is  destroyed  if  they  are  then  placed  in  the  average 
obstetric  bag,  which  contains  bottles  and  cotton,  and,  from  old 
age,  micro-organisms  of  every  possible  genus. 

The  sterilized  instruments  must  be  wrapped  in  a  sterilized 
napkin  or  towel  before  they  are  placed  in  the  bag,  and  imme- 
diately before  use  must  be  again  washed  in  hot  soap-suds  and 
next  boiled  in  the  1-per-cent.  soda  solution.  In  every  household 
the  washing-soda  will  be  found,  as  well  as  the  pot  in  which  to 
boil  them.  The  instruments  may  be  used  directly  from  this 
soda  solution  or  else  may  be  first  transferred,  with  aseptic  hands, 
into  a  5-per-cent.  solution  of  creolin, — a  solution  which  is  an 
efficient  antiseptic  and  yet  will  not  injure  the  instruments  as 
does  bichloride.  This  creolin  further  answers  the  purpose  of  an 
emollient.  If  there  is  one  thing  more  dangerous  to  the  patient 
than  another,  it  is  the  vaselin  which  it  is  customary  to  use  as 
an  emollient.  The  vaselin-pot  should,  once  and  for  all,  be 
banished  from  the  lying-in  chamber.  If  newly  opened  it  may 
not  contain  micro-organisms,  but  when  it  has  been  repeatedly 
exposed  to  the  air,  and  possibly  has  been  used  scores  of  times,  it 
will  be  found  a  veritable  culture-medium  for  bacteria.  Creolin 
will  answer  as  a  lubricant  for  the  finger  and  for  the  instruments, 
and  this  should  be  the  only  lubricant  allowed  in  the  lying-in 
room,  unless  the  physician  prefers  to  use  sterilized  oil. 

As  far  as  is  possible  the  physician  should  avoid  using  rub- 
ber instruments.  It  is  difficult  to  render  them  sterile.  The 
stronger  antiseptics  will  ruin  them,  the  weaker  will  not  asepti- 


OBSTETRIC    ASEPSIS    AND    ANTISEPSIS.  7 

cize  them.  Prolonged  boiling  may  sterilize  them,  but  often  at 
the  expense  of  their  integrity  and,  therefore,  of  their  utility. 
Glass  catheters  and  glass  irrigating-tubes  should  be  selected. 
These  may  be  boiled,  and  thus  be  rendered  safe  to  use.  The 
metal  catheter,  which  the  average  nurse  will  produce  with  pride, 
should  be  taken  from  her  and  returned  only  when  she  leaves 
the  case,  and  then  with  the  injunction  to  either  throw  it  away 
or  to  lock  it  up  and  to  forget  it.  Many  a  case  of  puerperal 
cystitis  has  been  traced  to  the  use  of  this  relic  of  pre-aseptic 
days. 

During  the  performance  of  an  obstetric  operation  sponges 
should  not  be  used.  This  is  another  article  which  should  have 
no  foothold  in  the  modern  lying-in  room.  Sterilized  towels  and 
sterilized  gauze  or  absorbent  cotton  should  take  the  place  of  the 
sponge.  In  every  household,  no  matter  how  humble,  there  is 
an  oven,  and  in  this  towels  and  gauze  may  be  baked.  If  the 
oven  is  lacking,  there  always  exists  a  means  for  boiling  them. 

For  purposes  of  irrigation  boiled  water  should  be  used.  To 
this  creolin  may  be  added  to  make  a  2-per-cent.  solution,  except 
where  it  is  essential  to  see  the  irrigated  portion,  and  then,  since 
the  milk-white  creolin  solution  will  obscure  vision,  bichloride 
solution  (1  to  5000)  must  be  substituted. 

Ligature  and  suture  material  must  be  absolutely  sterile. 
In  view  of  the  difficulty  of  obtaining  sterile  catgut  it  is  wise 
never  to  use  it.  The  ideal  suture  is  silk-worm  gut.  If  this  be 
boiled  for  ten  minutes  in  creolin — 5-per-cent.  solution — it  is 
rendered  aseptic,  and  is  further  rendered  pliable.  Obstetric  sur- 
gery being  often  emergency  surgery,  the  operator  has  not  the 
time  to  prepare  beforehand  his  catgut  and  silk  so  as  to  feel 
certain  about  them.  Further,  since  the  major  portion  of  ob- 
stetric work  falls  to  the  lot  of  the  busy  general  practitioner,  his 
precedent  preparations  must  be  as  simple  as  is  consistent  with 
absolute  asepticism. 

If  these  simple  rules  for  securing  asepsis  of  the  lying-in 
woman  and  her  surroundings  are  followed,  the  morbidity  rate 


8  OBSTETRIC     SURGERY. 

and  mortality  rate  in  private  practice  will  approximate  those 
which  are  secured  to-day  in  maternity  hospitals,  where  the 
mortality  rate  has  been  reduced  to  a  fractional  percentage,  and 
where  morbidity  from  sepsis  is  practically  abolished.  We  have 
endeavored  to  emphasize  our  belief,  and  this  is  the  current  be- 
lief, that  the  lying-in  w^oman  is  septicized  solely  through  personal 
contact.  By  this  we  mean  that  the  atmosphere  is  not  a  factor, 
and  that  the  infectious  material  does  not  originate  in  the  body 
of  the  woman.  The  sole  exception  to  this  latter  statement  is 
where,  during  the  progress  of  labor  or  during  obstetric  manipu- 
lation, a  pyosalpinx,  for  instance,  ruptures.  Such  an  event 
may  lead  to  septic  infection  of  the  woman,  but  then  the  sepsis 
cannot  be  properly  considered  an  obstetric  epi-phenomenon. 

Aseptic  and  elective  obstetrics  rob  labor  of  its  terrors  and 
the  puerperal  state  of  well-nigh  its  sole  risk. 


CHAPTER  I. 

OBSTETRIC  DYSTOCIA  AND  ITS  DETERMINATION. 

A  SCIENTIFIC  knowledge  of  the  configuration  of  the  female 
pelvis  and  of  the  methods  of  estimating  its  capacity  is  an  essen- 
tial prelude  to  the  practice  of  midwifery.  The  surgical  side  of 
the  art,  in  particular,  rests  its  results  on  accurate  pelvimetry. 
The  fate  of  the  woman  and  of  the  foetus  is  intimately  linked 
with  the  expertness  of  the  physician  in  determining,  before  or 
at  the  time  of  labor,  the  probable  capacity  of  the  pelvis  in  its 


Fig.  1.— Normal  Female  Pelvis. 


relation  to  the  estimated  size  of  the  foetus.  A  consideration, 
therefore,  of  the  surgical  means  at  our  disposal  for  assisting 
labor  or  for  facing  its  emergencies,  must  be  preceded  by  a  care- 
ful study  of  the  pelvis,  normal  and  abnormal. 

Furthermore,  the  pelvis  is  not  the  only  element  in  the 
problem  which  is  to  be  solved.  An  approximate  idea  of  the 
size  of  the  foetus  which  is  to  pass  through  the  birth-canal  is  also 
to  be  secured.  It  is  essential,  therefore,  to  precede  the  surgery 
of  parturition  by  a  description  in  brief  of  the  anatomy  of  the 
obstetric  pelvis  and  of  the  general  physical  features  of  the  foetus. 

(9) 


10 


OBSTETRIC     SURGERY. 


The  pelvis  is  formed  by  the  union  of  the  ossa  innominata 
with  the  sacrum.  The  sacrum  is  connected  with  the  vertebral 
column  above  and  with  the  coccyx  below.  The  resulting  canal 
is  larger  above  than  below,  and  is  flattened  to  a  degree  from  in 
front  backward.  The  superior,  wider  portion  constitutes  the 
greater  pelvis,  the  inferior  and  narrower  portion  the  lesser 
pelvis.      The    pelvis  is  further   subdivided  into  a  number  of 


Fig.  2. — Beaudelocque's  Pelvimeter. 


Fig.  3.— Martin's  Pelvimeter. 


straits,  the  entrance  into  the  canal  receiving  the  name  of  su- 
perior strait,  the  median  portion  constituting  the  middle  strait, 
the  exit  from  the  canal  the  inferior  strait.  It  is  the  determi- 
nation of  the  measurements  in  various  directions  of  these  three 
portions  which  is  termed  pelvimetry,  and  the  resultants  consti- 
tute the  diameters  of  the  pelvis.  The  diameters  of  the  pelvis 
are  to  be  obtained  both  externally  and  internally,  and  the  former 
stand  in  a  certain  relation  to  the  latter. 


OBSTETRIC    DYSTOCIA    AND    ITS    DETERMINATION. 


11 


Instruments  for  the  Determination  of  the  Pelvic 
Diameters. 

The  best-known  pelvimeter  is  that  devised  by  Beaude- 
locque.  In  view  of  the  fact,  however,  that  the  instrument 
should  be  portable,  the  Martin  pelvimeter  will  be  found  prefer- 
able.    It  should  ever  be  remembered  that  the  pelvimeter  is  as 


Fig.  4. — Schultze's  Pelvimeter. 


Fig.  5.— Collyers  Pocket  Pelvimeter. 


indispensable  to  the  obstetrician  as  is  the  microscope  to  the 
physiologist,  and,  therefore,  that  it  should  be  associated  with 
pregnancy  in  his  mind  as  the  forceps  is  with  labor.  (Figs.  2,  3, 
4,  and  5.) 

External  Diameters  of  PEL\^s. 

The  following  external  diameters  are  of  chief  obstetric 
significance :  The  distance  between  the  anterior  superior  spines 
of  the  ilium,  that  between  the  crests  of  the  ilium,  that  between 


12  OBSTETRIC     SURGERY. 

the  trochanters,  that  between  the  spinous  process  of  the  last 
lumbar  vertebra  and  the  centre  of  the  anterior  surface  of  the 
pubic  bones  (the  diameter  of  Beaudelocque).  These  are  the 
essential  measurements  which  are  to  be  obtained  by  means  of 
the  pelvimeter.  The  objection  which  has,  over  and  over  again, 
been  made  to  this  instrument,  that  the  patient  will  object  to  the 
exposure  which  it  entails,  will  not  hold,  for  the  reason  that  there 
need  be  none,  as  the  patient  is  covered  by  a  sheet;  and,  instead 
of  there  being  objection  made,  the  patient  will  have  a  higher 
opinion  of  the  physician  who  evidently  is  taking  every  requisite 
precaution  for  her  future  safety.  It  cannot  be  emphasized  too 
strongly  that  the  physician  is  to-day  not  guiltless  who,  whenever 
it  may  be,  does  not  practice  pelvimetry.     (See  Plates  I  and  II.) 

In  using  this  or  any  similar  instrument  the  utmost  care 
must  be  exercised  to  adapt  the  points  of  the  blades  accurately 
to  the  soft  parts  (as  is  purposely  shown  in  the  plates),  and,  in  in- 
stances where  it  is  of  considerable  importance  to  determine  with 
great  accuracy  the  exact  measurements,  it  is  advisable  that  these 
should  be  taken  by  two  persons  independently.  These  external 
measurements,  of  course,  give  us  purely  a  relative  idea  of  the 
internal,  but,  occasionally,  a  slight  diminution  beyond  the  nor- 
mal in  one  or  another  diameter,  may  turn  the  scale  in  favor  of 
one  over  another  obstetric  operation. 

The  following  external  measurements  may  be  taken  as  nor- 
mal in  the  average  case,  although  it  should  ever  be  remembered 
that  the  estimated  capacity  of  a  given  pelvis  depends  on  the 
estimated  size  of  the  foetus  which  must  pass  through  it : — 

Distance  between  the  spines,  .         .     10    to  10^  inches. 

Distance  between  the  crests,  .         .     10^  to  11    inches. 

Distance  between  the  trochanters,  .     12    to  12^  inches. 

Diameter  of  Beaudelocque,  ....  8    inches. 

The  most  important  of  these  external  diameters  is  that 
of  Beaudelocque.  By  means  of  this  €xternnl  conjugate  we 
are  enabled  to  approximate  the  true  conjugate, — that  is  to 
say,   the  diameter  of  the  pelvic  inlet, — the  distance  from   the 


PLATE    I. 


H 

fc_^.fe^jB 

1 

1 

1 

■ 

^^^^^^^^ 

T^^ 

g  /MM 

I 

1 

H 

^^^^P^ 

ri 

^Kk^^ 

"'^«l 

^^^  / 

'"ig 

'^ 

^ 

% 

» 

1 

2 

— 1^ 

^^B 

»v 

^ 

j^**- 

H 

"■■'5, 

^^ 

■ 

1 

I      '■- 

mi^ 

"  - 

^^HH 

BBp^'  '*i^^^ 

^ 

"' 

^3 

■  "  •  '  '  ■? 

Measurement   of   Distance   between   the   Spines. 


PLATE    II. 


Fig.   I. — Measurement  of   Beaudelocque    Diameter. 


Fig.    2. — Measurement  of   Beaudelocque    Diameter   in    Case   of   Pendulous  Abdomen. 


OBSTETRIC    DYSTOCIA    AND    ITS    DETERMINATION.  13 

upper  margin  of  the  pubic  symphysis  to  the  promontory  of  the 
sacrum.  In  general  it  may  be  stated  that  a  mean  deduction  of 
three  inches  from  the  measurement  of  the  external  conjugate 
will  give  us  that  of  the  true  conjugate.  As  regards  the 
other  external  diameters,  suffice  it  to  say  that  diminution 
below  the  foregoing  measurements,  which  represent  a  mean 
from  a  large  number  of  pelves  examined,  should  always  be 
a  source  of  thought  and  solicitude  to  the  physician.  This 
matter  will  be  amply  considered  under  the  heading  of  the 
various  operations. 

Internal  Diameters  of  Pelvis. 

Many  instruments  have  been  devised  for  determining  the 
internal  diameters.  The  finger  and,  if  need  be,  the  hand  of  the 
physician  best  subserve  the  purpose.  Obviously,  the  hand  can 
only  be  used  under  anaesthesia ;  but  in  every  instance  where 
the  determination  of  the  internal  diameters  is  of  moment  in  the 
selection  of  one  operative  procedure  over  anotlier,  in  view  of  the 
almost  absolute  safety  of  anaesthesia,  this  should  be  resorted  to. 
In  the  vast  majority  of  cases,  however,  digital  pelvimetry  yields 
us  sufficiently  exact  information  in  regard  to  the  capacity  of  the 
pelvis.  This  should  be  practiced  as  a  routine  measure  in  every 
case.  We  may  tlius  determine  the  diagonal  conjugate,  and, 
this  having  been  obtained,  the  true  conjugate  is  readily  ascer- 
tained by  deducting  the  estimated  depth  of  the  pubic  symphysis. 
The  transverse  and  oblique  diameters  may  also  be  thus  approx- 
imately measured.  To  perform  digital  pelvimetry  the  patient 
should  occupy  the  dorsal  position,  witli  tlie  nates  on  the  very  edge 
of  the  bed  or  couch.  The  index  and  the  middle  finger  of  the 
right  hand  are  introduced  into  the  vagina,  the  perineum  being  de- 
pressed as  much  as  possible.  The  aim  of  the  fingers  is  to  reach 
the  junction  of  the  sacrum  with  the  last  lumbar  vertebra,  for  it 
is  the  distance  from  this  point  to  the  lower  margin  of  the  sym- 
physis pubis  which  yields  the  diagonal  conjugate.  If  the  sacral 
promontory  cannot  be  reached,  the  inference  is  safe  that  the 


14  OBSTETRIC     SURGERY. 

pelvis  is  normal  as  regards  its  antero-posterior  diameter.  If  the 
promontory  can  be  reached,  then  the  wrist  is  carried  upward 
until  the  edge  of  the  index  finger  rests  against  the  pubic  sym- 
physis. The  index  of  the  other  hand  notes  this  subpubic  point, 
the  fingers  are  withdrawn,  and,  by  means  of  a  tape-measure  or 
the  pelvimeter,  the  distance  from  the  end  of  the  middle  finger 
to  the  noted  point  on  the  edge  of  the  index  is  measured.  This 
measurement  is  the  sacro-subpubic  or  the  diagonal  conjugate 
diameter.     (Plate  III,  Fig.  1.) 

According  to  the  estimated  depth  and  obliquity  of  the  sym- 
physis in  a  given  case,  it  is  necessary  to  deduct  from  one-fourth 
to  one-half  an  inch  from  this  measurement,  in  order  to  obtain 
the  dimension  of  the  sacro-suprapubic  or  true  conjugate  of 
the  pelvis. 

In  taking  the  above  measurement  it  should  be  remembered 
that  occasionally  the  first  sacral  vertebra  projects  over  the  second, 
forming  a  false  promontory.  To  avoid  mistaking  this  for  the 
true  sacral  promontory,  it  is  only  necessary  to  depress  the 
perineum  or  to  carry  the  fingers  as  high  upward  as  possible. 
Then,  in  the  event  of  the  existence  of  a  false  promontory,  the 
true  will  be  found  above  it. 

The  transverse  and  the  oblique  diameters  of  the  pelvis 
cannot  be  measured  with  the  same  exactitude  as  the  conjugate. 
As  a  general  rule,  it  may  be  stated  that,  when  the  promontory 
cannot  be  reached  in  a  symmetrical  pelvis,  labor  at  term  is  pos- 
sible with  a  foetus  of  average  size.  If  there  be  a -suspicion,  how- 
ever, of  a  deviation  from  the  normal  in  the  pelvis,  then  the 
welfare  of  the  woman  and  the  foetus  calls  for  anaesthesia,  in 
order  that  the  entire  hand  may  be  inserted  into  the  vagina,  so 
that  the  capacity  of  the  pelvis  may  be  determined.  This  point 
cannot  be  emphasized  too  strongly.  The  scientific  determina- 
tion of  the  operative  procedure  to  be  elected  in  the  presence  of 
an  abnormal  pelvis  depends  on  pelvimetry  as  accurate  as  pos- 
sible. The  instruments  which  from  time  to  time  have  been 
devised  for  the  purpose  of  internal  pelvimetry  cannot  take  the 


PLATE    III. 


Fig.    I. — Determination   of  the    Diagonal    Conjugate. 


Fig.    2. — Depression   of  the    Uterus   so    as   to    Determine   Adaptability   of  Presenting 
Part  to  the    Pelvic    Brim. 


OBSTETRIC   DYSTOCIA    AND    ITS    DETERMINATION.  15 

place  of  the  finger  and  hand ;  further,  outside  of  maternity  hos- 
pitals these  instruments  will  rarely  be  at  the  disposal  of  the 
practitioner.  Usually,  fortunately,  the  careful  measurement  of 
the  external  diameters  of  the  pelvis  and  the  accurate  estimation 
of  the  true  conjugate  will  give 'a  sufficient  estimate  of  the 
capacity  of  the  pelvis.  Where  the  estimate  thus  obtained  falls 
below  the  normal,  we  repeat,  manual  pelvimetry  under  anaes- 
thesia is  called  for.  Further,  in  the  presence  of  a  contracted 
pelvis,  we  thus  not  alone  note  the  capacity  of  and  shape  of  the 
pelvis,  but  we  also — and  this  is  of  equal  importance — may  form 
an  approximate  idea  of  the  size  of  the  foetal  presenting  part. 
(Plate  III,  Fig.  2.)  Whilst  the  hand  is  in  the  pelvis  the  uterus 
may  be  depressed,  and  the  facility  with  which  the  presenting 
part  is  likely  to  engage  within  the  pelvic  inlet  may  be  noted. 
Far  too  little  stress  is  laid  on  the  relation  which  the  foetus  bears 
to  the  canal  through  which  it  must  pass  into  the  world.  A 
given  pelvis  may  be  large  enough,  although  diminished  in  all 
its  diameters,  for  a  foetus  below  the  average  size,  and  the  reverse 
is  equally  true.  Could  we  solve  as  approximately  the  size  of 
the  foetus  as  we  can  the  capacity  of  the  pelvis,  the  surgical  side 
of  obstetrics  would  be  much  simplified.  As  yet,  however,  we 
may  only  form  an  imperfect  and  relative  idea  of  the  ease  wdth 
which  the  foetal  presenting  part  will  enter  the  pelvic  canal.  In 
general,  however,  if  a  foetus  can  engage  at  the  pelvic  inlet  the 
chances  are  that  it  can  engage  at  the  outlet,  unless,  indeed,  the 
alteration  in  shape  of  this  outlet  is  marked  enough  to  be  deter- 
mined even  by  digital  pelvimetry. 

Aside  from  the  conjugate,  the  internal  diameters  of  the 
pelvis  which  the  practitioner  should  estimate  in  the  average 
case  are  as  follow,  with  the  dimensions  necessary  for  the  birth 
of  the  average  foetus : — 


Diameters. 

Brim. 

Cavity. 

Outlet. 

Transverse, 

5    in. 

5  to  5^  in. 

4|  in, 

Oblique, 

.     4^  to  5     in. 

5  to  5^  in. 

4|  in, 

Conjugate, 

.     4^  to  4^  in. 

4|  in. 

5    in. 

16  OBSTETRIC     SURGERY. 

It  will  be  noted  from  these  figures  that  in  the  normal 
pelvis  the  transverse  diameter  is  widest  at  the  brim  and  nar- 
rowest at  the  outlet ;  the  obhque  is  widest  in  the  cavity  and 
narrowest  at  the  outlet;  the  antero-posterior  is  widest  at  the 
outlet  and  narrowest  at  the  brim.  Therefore,  a  foetus  of  average 
size,  engaging  normally  at  the  brim,  can  pass  without  assistance 
through  the  cavity  and  emerge  at  the  outlet,  if  the  estimate 
of  the  pelvic  capacity  do  not  fall  below  these  figures.  Where 
the  obtained  measurements  are  below  these  figures,  we  are  in 
face  of  an  abnormal  pelvis,  and  the  degree  of  abnormality  in 
relation  to  the  estimated  size  of  the  foetus  must  be  carefully 
weighed  before  we  are  in  a  position  to  determine  the  measures, 
if  any,  which  are  requisite  for  the  safe  conduct  of  the  labor. 

A  further  measurement  to  be  taken  is  the  circumference. 
This  is  chiefly  of  importance  in  determining  asymmetry  of  the 
pelvis.  ^  The  circumference  may  be  secured  by  means  of  a  tape- 
measure.  Failing  this  the  pelvimeter  may  be  utihzed  by  meas- 
uring each  lateral  half  separately.  This  latter  method  will  best 
enable  us  to  secure  knowledge  in  reference  to  pelvic  asymmetry. 

Before  entering  into  a  consideration  of  deviation  of  the 
pelvis  from  the  normal,  it  is  essential  to  recall  briefly  the  aver- 
age dimensions  of  the  foetus  at  term,  for,  as  already  stated,  the 
practitioner  must  take  into  account  in  his  estimate  not  alone 
the  probable  capacity  of  the  given  pelvis,  but  also  the  probable 
size  of  the  body  which  must  pass  through  this  pelvis. 

The  weight  of  the  average  foetus  at  term  varies  from  6i  to 
7i  pounds,  and  the  length  is  about  20  inches.  The  chief  diam- 
eters of  the  foetal  head,  with  their  measurements,  are : — 


Occipito-frontal, 
Occipito-meiital, 
C  erv  ico-bregmatic , 
rronto-mental,    . 
Suboccipito-bregmatic, 
Biparietal, , 


4|  inches. 
5^  inches. 
3|  inches. 
3^  inches. 
3^  inches. 


.     3|  inches. 
It  should  ever  be  remembered  that  during  the  course  of 


OBSTETRIC    DYSTOCIA    AND    ITS   DETERMINATION.  17 

labor  some  of  these  diameters,  owing  chiefly  to  tlie  presence  of 
the  fontanelles,  are  capable  of  diminution,  always,  however,  at 
the  expense  of  others.  In  tlie  course  of  a  normal  labor  the 
molding  of  the  foetal  head  as  it  descends  flexes  and  rotates 
in  the  pelvis,  results  in  diminution  of  those  diameters  which 
adapt  themselves  to  the  most  favorable  diameters  of  the  pelvis, 
and  the  corollary  is  that  in  case  of  abnormal  pelvis  the  aim  of 
the  attendant  should  be  to  guide  the  longest  diameters  of  the 
fcetal  head  into  the  longest  diameters  of  the  pelvic  canal.  Such 
an  aim  presupposes  accurate  knowledge  of  pelvic  configura- 
tion, and  hence  a  further  reason  for  accurate  pelvimetry  in 
every  case.  The  problem  before  the  physician  is  rarely  a  simple 
one,  and  as  we  pass  from  a  consideration  of  the  normal  pelvis 
to  that  of  the  abnormal  pelvis  this  problem  becomes  all  the 
more  complex. 

General  Considerations  of  Abnormal  Pelves. 

On  the  accurate  determination,  as  far  as  possible,  of  the 
degree  of  pelvic  abnormality  in  relation  to  the  estimated  size 
of  the  foetus  depends  the  scientific  selection  of  the  operative  pro- 
cedure which  offers  the  fairest  chance  both  to  the  woman  and 
to  the  foetus.  Only  through  the  deliberate  election,  in  a  given 
case,  of  a  determinate  operative  procedure  can  the  physician 
plead  that  he  has  done  his  whole  duty  by  the  two  beings  whose 
welfare  depends  on  his  skill.  The  midwifery  of  the  present 
differs  in  many  respects  from  that  of  the  past.  In  no  respect  is 
the  difference  more  striking  than  in  the  growhig  tendency  to 
elect  the  proper  operation  before,  in  the  face  of  maternal  and  of 
foetal  exhaustion,  it  is  forced  upon  us. 

Careful  inquiry  into  the  antecedents  of  the  patient;  inspec- 
tion, Avhere  need  be,  of  the  general  configuration  of  the  body, — 
data  of  this  kind  are  essential  aids  in  the  determination  of  the 
nature  of  pelvic  abnormality.  Diseases  of  early  life,  such  as 
rachitis  and  marasmus,  almost  inevitably  leave  their  impress  on 
the   pelvis, — an   impress   which  superficial   pelvic   examination 


18 


OBSTETRIC     SURGERY. 


mav  not  reveal. — -but  the  knowledge  of  Avhicli  ^vill  nra-e  the 
physician  to  brina'  all  his  skill  to  bear  on  a  more  carei'ul  and 
thorough  examination  of  the  pelvis. 

The  abnormalities  of  tlie  female  pelvis  may  be  conveniently 
divided  into  minor  and  major,  cummon  and  uncommon.  In  the 
United  States  the  major  delormities  are  rarely  met  witli.  l)ut  their 
determination  is  a  far  simpler  matter  than  that  of  the  minor 
deviations  from  the  normal.  It  i-  in  the  latter  class  of  cases 
that  extreme  accuracy  is  refpii>ire.  since  at  times  shades  of  dif- 
erence  may  turn  the  =rale  in  favor  nf  one  or  another  operative 


Fig.  6. — ^Justo-Major  Pelvis. 

procedure.  In  instances  of  major  deformity  the 'choice  of  oper- 
ation will  ordinarily  be  limited,  in  tlie  presence  of  a  foetus  of 
avera£:e  size,  within  a  very  narrow  ran2"e. 

The  varieties  of  pelvic  deformitv  and  the  salient  character- 
istics of  f-ach  are  as  follow: — 

/.  Jusio-Mojor  Felc'i.^. — The  ecpaaliy  erdara'ed  pelvis  is  of 
obstetric  significance  only  in  so  far  as  it  may  lead  to  precipitate 
labor  or  to  prolapse  of  the  funis.  It  is  not  a  variety  of  pelvic 
abnormality  Avliich  is  at  all  likely  to  rail  for  operative  inter- 
ference.     Extfrrnal  pjelvimetrv  will  readily  diagnosticate  the  con- 


OBSTETRIC    DYSTOCIA    AND    ITS    DETERMINATION.  19 

dition,  seeing  that  the  diameters  obtained  exceed  the  measure- 
ments which  have  been  stated  as  normal.  The  diagnosis, 
therefore,  is  chiefly  of  value  as  warning  the  attendant  of  the 
possible  complications  just  mentioned,  in  order  that  he  may  be 
prepared  to  meet  tbem.  Precipitate  labor  may  mean,  for  the 
woman,  post-partum  hsemorrhage,  inversion  of  the  uterus,  lacer- 
ation of  the  genital  tract,  and  prolapse  of  the  cord  may  entail 
foetal  death. 

//  TJieJasto- Minor  Pelvis. — This  form  of  pelvic  deformity 
is  of  infrequent  occurrence.  The  external  configuration  of  the 
patient  and  her  antecedent  history  may  give  us  no  clue  to  its 
presence.     It  is  only  through  careful  pelvimetry,  external  and 


Fig.  7. — Generally  Equally  Contracted  Pelvis  ( Justo-Minor) . 

internal,  that  tbe  diagnosis,  ordinarily,  may  be  readied.  All 
the  diameters  of  the  pelvis  are  diminished  to  a  greater  or  less 
degree,  and  it  is  apparent  how  essential  it  is  to  determine  the 
amount  of  diminution  in  order  to  elect  the  proper  operative 
procedure  in  any  instance  where  the  estimated  size  of  the  foetus 
suo-"-ests  that  assistance  will  be  needed.  In  general,  it  mav  be 
stated,  that  in  the  presence  of  this  variety  of  pelvic  deformity,, 
certainly  in  all  but  the  lesser  grades,  it  is  advisable  to  explore 
the  pelvis  manually  (under  anaesthesia),  in  order  to  determine, 
as  approximately  as  possible,  the  length  of  the  transverse  and 
oblique  diameters  from  the  brim  to  the  outlet.  In  reported 
instances  the  diminution  in  the  diameters  has  amounted  to  an 


20 


OBSTETRIC     SURGERY. 


inch  and  over.  Early  recognition  of  this  type  of  pelvis,  there- 
fore, might  suggest  the  induction  of  premature  labor  :  if  tlie 
time  for  this  operation  had  elapsed  the  question  of  choice 
between  forceps  and  version  might  arise ;  in  the  extreme 
decrees  of  contraction  the  deliberate  election  of  svmphvsi- 
otomv,  the  Caesarean  section,  or  of  embryotomy  would  offer  as 
alternatives. 

III.  The  Flattened  Pelvis. — This  abnormality  of  the  pelvis 
may  be  met  with,  like  the  preceding,  in  women  of  normal  ex- 
ternal configuration  and  of  healthy  antecedents.  It  is  a  type  of 
pelvis  very  frequently  found,  so  much  so,  indeed,  that  many 
authorities  rank  it  as  the   most  frequent  variety  of  deformity. 


Fig.  8.— Flat  Xon-Kacliitic  Pelvis. 


The  etiological  cause  can  rarely  be  definitely  stated.  This 
pelvis  is  found  amongst  all  classes,  the  wealthy  as  well  as  the 
poor,  amongst  those  subjected  to  privations  in  ii>fancy  and  to 
toil  before  maturity,  and  those  who  are  reared  Avitli  tenderest 
care  from  the  start.  Pelvimetry  alone,  in  the  vast  proportion 
of  cases,  will  reveal  the  abnormality,  and  that  its  recognition  is 
important  is  apparent  when  we  recall  the  well-known  fact  that 
this  deformity  is  a  frequent  source  of  the  most  deplorable  results 
in  childbirth. 

The  diagnosis  of  this  form  of  pelvic  deformity  rests  on  the 
fact  that  there  is  narrowing  in  the  external  conjugate  whilst,  as 
a  rule,  the  other  diameters  are  normal.     The  transverse  diam- 


OBSTETRIC    DYSTOCIA    AND    ITS    DETERMINATION. 


21 


eter  may  be  increased ;  there  is  no  pelvic  asymmetry.  '  The  true 
conjugate  measures,  generally,  about  three  inches. 

From  a  surgical  stand-point,  bearing  these  characteristics  in 
mind,  the  recognition  of  this  form  of  pelvic  deformity  tells  the 
physician  that  his  aim,  in  case  of  difficulty  in  extraction,  should 
be  to  guide  the  largest  diameter  of  the  fcetal  presenting  part 
into  the  largest  diameter  of  the  pelvis.  In  other  words,  labor 
through  this  type  of  pelvis  requires  constant  watchfulness  on 
the  part  of  the  accoucheur.  It  is  only  by  not  trusting  to  nature 
overmuch  that  deplorable  results,  chiefly  from  the  foetal  side, 
may  be  avoided.  Here,  again,  the  question  of  the  election  of 
version  or  forceps  will  often  be  forced  on  the  physician. 


Pig.  9.— Flat  Rachitic  Pelvis  (Mild  Grade). 


IV.  The  Racliitic  Pelvis. — In  certain  sections  of  Europe 
the  rachitic  type  of  pelvis  is  very  commonly  met  with.  In  the 
United  States,  except  among  our  foreign-born  population,  this 
pelvis  is  infrequent  compared  with  the  simple  flat  pelvis.  The 
external  conflguration  of  the  woman  may  or  may  not  suggest 
the  presence  of  rachitic  deformity.  Inquiry  into  the  early  history 
of  the  patient  will,  however,  generally  give  the  requisite  clue. 
Often,  in  marked  instances,  the  appearance  of  the  patient  is 
characteristic  ;  the  size  is  dwarfed ;  the  abdomen  prominent ; 
the  gait  clumsy  ;  the  sacrum  is  flattened  externally  in  outline ; 
a  variable  amount  of  spinal  deviation  may  be  present.     External 


22 


OBSTETRIC     SURGERY. 


pelvimetry  will  reveal,  as  a  rule,  diminution  (slight  in  the  minor 
degrees  of  deformity)  in  the  measurements  between  the  crests 
and  the  spines.  The  external  conjugate  is  always  diminished. 
These  results  call  for  internal  pelvimetry  under  ansestliesia,  for 
the  hand  alone,  exploring  the  pelvis,  can  give  us  sufficiently 
accurate  data  as  to  the  degree  of  deformity.  The  pelvic  capacity 
will  be  found  to  be  generally  limited.  The  pelvis  is  often  asym- 
metrical. 

The  most  marked  internal  change  is  due  to  the  downward 
sinking  of  the  sacrum,  the  result  being  approximation  of  the 
promontory  to  the  symphysis.     This  antero-posterior  shortening 


Fig.  10.— Flat  Rachitic  Pelvis  (High  Grade). 


may  be  compensated  by  a  slight  increase  in  the  transverse  di- 
ameter, but  this  is  not  the  rule  in  the  typical  rachitic  pelvis. 
The  pubic  arch  is  generally  widened.  The  total  result  of  these 
alterations  is  a  pelvis  with  contraction  at  the  brim,  whilst  the 
outlet  may  be  normal  or  slightly  widened. 

In  the  extreme  degree  of  this  deformity  the  approximation 
of  the  sacral  promontory  to  the  symphysis  may  be  such  as  to 
practically  divide  the  brim  of  the  pelvis  into  two  portions. 

The  importance  of  the  recognition  of  this  pelvis  before 
labor,  is  at  once  obvious.  The  contraction  at  the  brim  neces- 
sarily interferes  with  the  normal  engagement  of  the  foetal  pre- 
senting  part!      The    safety    of   the    foetus,    certainly,    depends 


OBSTETRIC    DYSTOCIA    AND    ITS    DETERMINATION.  23 

therefore  on  the  diagnosis  of  the  deformity  before  long-continued 
efforts — leading  to  maternal  and  foetal  exhaustion — at  engage- 
ment have  been  made.  Here,  again,  it  is  evident  how  accurate 
pelvic  exploration  before  labor  may  teach  the  physician  that  his 
patient  has  a  pelvis  where  the  judicious  election  of  one  or 
another  obstetric  operation  will  redound  to  tlie  safety  of  the 
child  if  not  always,  in  this  deformity,  of  the  mother.  In  minor 
degrees  of  the  deformity,  even,  the  foetal  head  cannot  enter 
the  pelvic  brim  obliquely  (as  is  normal).  The  physician,  for 
instance,  if  he  recognize  this,  may  conclude  that  the  chances 


Fig.  11.— Generally  Contracted  Flat  Rachitic  Pelvis. 

for  the  foetus  are  better  if  he  perform  version  and  guide  the 
largest  diameters  of  the  head  through  tlie  largest  of  the  pelvis. 
The  brim  once  passed,  there  will  be  rarely  difficulty  in  the 
further  progress  of  labor  in  the  pure  rachitic  type  (mild)  of 
pelvis. 

The  pelves,  the  characteristics  of  which  have  been  tersely 
passed  in  review,  constitute  the  varieties  with  which  the  prac- 
titioner will  ordinarily  come  in  contact.  As  a  rule,  these  pelves, 
except  the  higher  grades  of  rachitic  deformity,  rarely  suggest 
themselves  from  inspection  of  tlie  general  configuration  of  the 
patient.     The  varieties  which  are  next  to  be  considered  are  of 


24 


OBSTETRIC     SURGERY. 


rare  occurrence,  certainly  in  English-speaking  countries,  and,  as 
a  rule,  the  appearance  of  the  woman  at  once  suggests  the  ex- 
istence of  pelvic  deformity.  Accurate  pelvimetry,  however,  is 
none  the  less  requisite,  seeing  that  due  recognition  of  the  exact 
deformity  may,  the  time  being  opportune,  point  infallibly  to  the 
necessity  of  the  induction  of  premature  labor  or  even  to  arti- 
ficial abortion,  in  order  to  avoid  at  term  embryotomy  of  the 
living  foetus  in  instances  where  the  indication  for  the  Csesarean 
section  is  not  absolute,  and  yet,  where  this  operation  cannot,  for 
one  or  another  reason,  be  deliberately  elected, 

(a)  Tlie  Transversely  Contracted  Pelvis. — This  type  is  also 
known  as  Koberts's  pelvis  from  the  fact  that  he  first  described  it. 


Fig.  12. — Roberts's  Pelvis.    The  Tiansverselj-  Contracted  Pelvis. 

It  is  an  uncommon  variety  of  pelvic  deformity,  only  about 
thirteen  instances  being  on  record.  Tlie  chief  internal  cliar- 
acteristic  of  this  pelvis  is  its  division  into  two  li^lves  antero- 
posteriorly.  This  is  due  to  progressive  narrowing  of  the 
transverse  diameter  from  the  brim  to  the  outlet.  The  conjugate 
diameter,  on  the  other  hand,  differs  but  little,  if  any.  from  tlie 
normal.  The  sinking  of  the  sacrum  into  the  pelvis  is  marked, 
the  posterior  superior  spines  are  close  together,  and  the  iliac 
bones  project  greatly  posteriorly. 

{h)  The  Kyphotic  Pelvis. — Inspection  of  the  patient  and 
the  antecedent  history  will  at  once  suggest  this  deformity.  The 
etiological  cause  is  Pottos  disease,  and,  according  as  this  disease 
has  affected  one  or  another  portion  of  the  spinal  column,  the 


OBSTETRIC    DYSTOCIA    AND    ITS   DETERMINATION. 


2o 


anterior  deviation   of  the   column  is  in  the  dorsal,  lumbar,  or 
sacral  region. 

The  effect  of  the  spinal  deviation  on  the  pelvis  is  variable. 
In  general,  however,  the  pelvis  offers  the  following  characteris- 
tics :  The  true  conjugate  is  increased,  the  transverse  diameter  is 
lessened  at  the  brim,  diminished  in  the  cavity,  and  still  more  so 
at  the  outlet.  The  sacrum  is  carried  upward  and  backAvard ;  the 
pubic  arch,  as  a  rule,  is  narrowed.  Where  Pott's  disease  has 
developed  in  infancy,  the  total  result,  as  regards  the  pelvis,  is 


Fig.  13. — The  Kyphotic  Pelvis,  showing  Nairo\\ing  in  the  Transverse  Diameter 
and  Lengthening  in  the  Conjugate. 

that  its  growth  is  arrested.  This  pelvis,  in  general,  will  call  for 
the  induction  of  premature  labor,  for  at  term  the  choice  will 
almost  necessarily  lie  between  the  Csesarean  section  and  embry- 
otomy, except  in  an  instance  of  very  small  foetus. 

(c)  TIw  Scoliotic  Pelvis. — It  is  essential  to  differentiate  two 
types  of  scoliotic  pelvis, — the  rachitic  and  the  non-rachitic, — for 
the  characteristics  are  markedly  different. 

In  case  of  the  non-rachitic  scoliotic  pelvis  the  diminution 
in  the  diameters  is  only  exceptionally  great  enough  to  prevent 
delivery  at  term.     The  chief  characteristics  of  the  pelvis  are : 


26 


OBSTETRIC     SURGERY. 


The  side  of  the  pelvis  toward  which  the  spinal  column  deviates 
is  flattened  to  a  greater  or  less  degree.  As  a  result  one  of  the 
oblique  diameters  is  shortened,  but  the  other  may  not  be  altered. 
The  pelvic  inlet  is  chiefly  the  seat  of  contraction. 

The  rachitic  scoliotic  pelvis,  on  the  other  hand,  presents 
alterations   which  differ  in   degree  according   as    the   rachitic 


Fig.  14. — Non-Rachitic  Scoliotic  Skeleton.       Fig.  15. — Rachitic  Scoliotic  Slieleton. 

changes  have  supervened  in  early  infancy  or  later.  Leopold 
states  the  following  as  the  striking  characteristics  of  this  pelvis : 
There  is  considerable  shortening  of  the  true  conjugate  owing 
to  the  projection  forward  of  the  sacral  promontory.  There  is 
greater  or  less  asymmetry  of  the  pelvis  according  to  the  degree 
of  lateral  curvature  of  the  spinal  column.  The  symphysis  of 
the  pubes  is  deviated  toward  the  side  opposite  the  scoliosis. 


OBSTETRIC    DYSTOCIA    AND    ITS    DETERMINATION. 


27 


At  the  pelvic  inlet  there  is  contraction  on  the  side  of  the 
scoliosis  and  widening  on  the  other,  whilst  at  the  outlet  the 
reverse  holds  true.  The  antero-posterior  diameter  is  here  dimin- 
ished, but  more  to  the  same  degree  than  the  true  conjugate. 

In  the  usual  variety  of  scoliosis  the  dorsal  vertebral  column 
is  curved  toward  the  right,  and  the  compensatory  lumbar  curve 
is  toward  the  left ;  the  pelvic  capacity,  therefore,  is  ordinarily 
diminished  on  the  right.  If  the  foetus  can  be  borne  spontane- 
ously, it  must  be  through  the  wider  (left)  half  of  the  pelvis, 


Fig.  16.-^poiidylolistlietic  Pelvis. 


and  in  a  given  case,  where  the  scoliosis  is  right-sided,  the  phy- 
sician in  his  manipulations  should  remember  that  it  is  within 
the  left  half  of  the  pelvis  that  he  can  alone  work. 

(c/)  SiDondyJolistJietic  Pelvis. — This  pelvis  results  from  the 
sliding  downward  of  one  or  more  of  the  lumbar  vertebrae  on 
the  first  sacral  vertebra,  forming  a  false  promontory  anterior  to 
and  below  the  true.  The  result  is  marked  narrowing  in  the 
conjugate, — to  such  a  degree,  in  extreme  cases,  that  the  foetus 
cannot  enter  the  pelvic  cavity.     The  deformity  was  first  described 


28  OBSTETRIC     SURGERY. 

by  Kiliaii.  Neugebauer  has  most  elaborately  studied  it,  and, 
as  a  result  of  his  analysis  of  forty-three  cases,  he  reaches  the 
conclusion  that  the  deformity  is  not  the  result  of  a  dyscrasia, 
but  of  the  physiological  weight  of  the  trunk.  This  explana- 
tion, however,  hardly  accords  with  the  data  furnished  by  the 
museum  specimens,  seeing  that  in  the  majority  there  is  evidence 
of  the  destruction  of  one  or  more  of  the  lumbar  or  sacral  verte- 
brae, suoo-estin"'  Pott's  disease  as  a  causative  factor. 

The  recognition  of  the  deformity  offers  no  difficulty.  The 
contour  of  the  lumbar  spine  at  once  suggests  deformity,  and 
digital  internal  pelvimetry  reveals  the  nature  of  the  obstruction. 
This  form  of  pelvis,  if  detected  early  enough,  calls  for  the 
induction  of  preniature  labor.  At  term  the  indication  for  the 
Csesarean  section  may  be  absolute. 

(e)  Funnel- Shaped  Pelvis. — This  variety  is  so  exceedingly 
rare  as  to  call  for  but  passing  notice.  The  name  accurately 
describes  the  appearance  of  the  pelvis.  There  is  slight  contrac- 
tion in  all  the  diameters  at  the  pelvic  inlet,  and  this  narrowing 
increases  progressively  to  the  outlet.  Recognition  is  easy  if 
internal  pelvimetry  be  not  neglected,  and,  again,  we  have  a 
pelvis  where  wise  conservatism  will  counsel  the  induction  of 
premature  labor,  for  at  term  the  choice  will  almost  inevitably 
lie  between  the  Csesarean  section  and  embryotomy. 

(/)  The-  Osteomalacic  Pelvis. — The  disease  causing  this 
deformity  usually  develops  after  puberty,  appearing,  as  a  rule, 
during  the  gravid  state.  The  early  stages  of  the  disease  are 
characterized  by  the  presence  of  acute  pain  in  the  limbs  and 
pelvis,  and  this  symptom  during  pregnancy  should  suggest  the 
development  of  the  disease,  and  should  call  for  careful  pelvic 
mensuration  by  means  of  the  entire  hand.  The  disease  is  very 
rare  in  the  United  States.  In  Italy  and  in  certain  portions  of 
lower  Germany  it  is  frequently  met  with.  The  etiological  causes 
are  the  same  as  those  of  rickets  ;  but,  except  in  advanced  cases, 
the  external  configuration  of  the  woman  will  not  suggest  the 
pelvic  deformity. 


OBSTETRIC    DYSTOCIA    AND    ITS    DETERMINATION. 


29 


The  characteristics  of  the  osteomalacic  pelvis  are  :  The 
bones,  in  general,  are  softened ;  the  sacrum  is  small,  the  promon- 
tory sinking-  into  the  pelvis  and  approximating  the  symphysis. 
The  lumbar  vertebrae,  in  consequence,  approach  the  pelvic 
brim.  The  rami  of  the  pubes  bend  inward,  the  pubic  angle 
being  sharply  acute  and  shaped  like  a  beak.  The  external 
measurement  between  the  iliac  spines  is  less  than  normal,  and 
that  between  the  crests  exceeds  that  between  the  spines.  As  a 
rule,  the  outlet  of  the  pelvis  is  narrower  than  the  inlet.  AVhilst 
the   conjugate  diameter   may  be   only   slightly   narrowed,  the 


Fig.  17. — The  Osteomalacic  Pelvis. 

transverse  is  considerably  so  at  the  brim  and  more  so  in  the 
cavity  and  at  the  outlet. 

In  the  slighter  degrees  of  deformity  due  to  osteomalacia, 
internal  pelvimetry  by  the  entire  hand  is  absolutely  essential 
not  alone  for  accurate  diagnosis,  but  also  for  determining  the 
extent  to  which  the  softened  pelvic  bones  can  be  made  to  yield 
to  pressure.  It  is  very  essential  to  determine  this  latter  point, 
for  on  this  depends  the  determination  of  delivery  i^er  vias 
naturaJes  with  safety  to  the  woman.  In  many  of  the  reported 
instances  of  osteomalacia  the  indications  for  Ceesarean  section 


30 


OBSTETRIC     SURGERY. 


have  been  absolute.  Of  72  cases  collected  by  Litzmann,  38 
could  not  be  delivered  naturally.  It  is  also  to  be  remembered 
that  the  disease  is  aggravated  in  successive  pregnancies. 

If  recognized  in  time,  the  osteomalacic  pelvis  calls  for  the 
induction  of  premature  labor;  in  aggravated  instances,  for  arti- 
ficial abortion.  If  determined  only  at  term,  whilst  the  pelvis 
may  yield  sufiiciently  to  allow  of  the  delivery  of  the  foetus,  in 
the  vast  proportion  of  cases  the  physician  will  be  called  upon  to 
elect  either  embryotomy   or    the    Csesarean   section, — here,  as 


Fig.  18.— Obliquely  Distorted  Pelvis  of  Naegele. 

always  prior  to  maternal  exhaustion,  the  result  of  ineffectual 
efforts  at  delivery. 

(g)  The  Oblique  Ovate  Pelvis. — This  form  of  pelvic  de- 
formity was  first  described  by  'Naegele.  As  a  rule,  the  woman 
off"ers  no  external  signs.  The  broad  characteristics  of  the  pelvis 
are  the  diminution  of  one  oblique  diameter  associated  with 
ankylosis  of  one  of  the  sacro-iliac  synchondroses.  The  pelvis  is 
asymmetrical,  one  side  of  the  sacrum  is  lacking  in  development, 
and  the  bone  is  pushed  toward  the  affected  side.  The  pubic 
symphysis  is  obliquely  opposite  the  sacrum.     The  arch  of  the 


OBSTETRIC    DYSTOCIA    AND    ITS    DETERMINATION.  3i 

pubes  is  narrowed.  The  true  conjugate  is,  as  a  rule,  longer 
than  normal;  the  transverse  is  narrowed  at  the  brim,  and  this 
narrowing  increases  progressively  toward  the  outlet.  Pelvic 
mensuration  of  the  lateral  halves  will  reveal  the  asymmetry. 

In  aggravated  instances  the  rule  as  regards  the  external 
configuration  will  not  hold.  The  woman  limps,  one  hip  is 
higher  than  the  other,  and  deviation  of  the  pubes  is  marked. 
In  such  an  instance  the  following  measurements,  which  are  the 
same  in  a  normal  pelvis  and  shorter  on  the  affected  side  in  the 
oblique  ovate  pelvis,  should  be  taken  as  assisting  in  diagnosis : 
From  the  tuberosities  of  the  ischium  to  the  opposed  posterior 
superior  spines  of  the  ilium  ;  from  the  anterior  superior  to  the 
opposite  posterior  superior  spines ;  from  the  spinous  process  of 
the  last  lumbar  vertebra  to  the  anterior  superior  spines.  These 
measurements  may  readily  be  taken  with  the  pelvimeter.  The 
oblique  ovate  pelvis  is  of  not  infrequent  occurrence.  The  neces- 
sity of  recognition  is  apparent  from  the  statement  that  in  a 
series  of  instances  collected  by  Litzmann,  22  out  of  28  women 
died  and  out  of  41  children  31  were  lost.  Such  results  are  ex- 
plainable alone  on  the  assumption  that  the  variety  of  deformity 
was  not  recognized  before  term.  This  pelvis  calls  strictly  for 
the  induction  of  premature  labor  in  order  to  avoid  the  choice  at 
term  between  the  Csesarean  section  and  embryotomy.  Only  ex- 
ceptionally, and  then  in  the  lesser  degree  of  the  deformity,  can 
spontaneous  labor  at  term  occur,  or  will,  at  this  time,  version  or 
the  forceps  be  safe  for  the  woman.  Symphysiotomy  is  contra- 
indicated. 

(7i)  Pelves  Deformed  hjj  Tumors. — The  presence  of  tumors 
within  the  pelvic  cavity  obviously  interferes  with  the  progress 
of  labor  and  may  even  render  delivery  by  the  natural  passages 
impossible.  These  tumors  may  be  bony  projections  (exostoses), 
osteosarcomata,  carcinomata,  fibroids  of  the  uterus,  ovarian 
cysts ;  such,  at  least,  are  the  common  varieties.  According  to. 
the  size  of  these  tumors  will  vary  the  obstetric  operation  requi-. 
site  for   delivery.     Ordinarily  their  presence  may   be   detected. 


32 


OBSTETRIC     SURGERY. 


only  by  exploration  of  the  pelvis ;  hence  a  further  reason  for 
the  rule  already  dwelt  upon, — the  necessity  for  examining  the 
pelvis  of  every  gravid  woman  at  an  early  date  of  gestation. 
Such  a  rule,  if  ordinarily  followed,  and  if  its  necessity  be 
recognized  by  every  woman,  will,  time  and  again,  result  in  the 
choice  of  a  minor  operative  procedure, — such  as  artificial  abor- 
tion or  the  induction  of  premature  labor,  in  instances  where,  if 
the  woman  be  only  examined  at  term,  the  indication  for  the 
Csesarean  section  may  be  absolute.  Further,  in  case  of  pedicu- 
lated  fibroids,  for  instance,  the  risk  resulting  from  impaction 
within  the  brim  may  be  avoided  where  the  woman  is  seen  in 
the  early  stage  of  gestation,  seeing  that,  at  times,  manipulation 


Fig.  19. — Osteosarcoma  of  the  Pelvis. 


in  the  proper  position — the  knee-chest — may  enable  the  phy- 
sician to  push  the  growth  above  the  brim  ;  and  in  case  of  an 
ovarian  cyst,  for  instance,  the  advisability  of  abdominal  section 
for  its  removal  might  well  be  forced  on  the  physician. 

The  osseous,  cancerous,  sarcomatous  tumors  which  spring 
from  the  walls  of  the  pelvic  cavity  will,  as  a  rule,  if  not  de- 
tected till  term,  call  for  embryotomy  or  for  the  Caesarean  sec- 
tion, possibly  for  the  Porro  operation.  It  must  be  recognized 
as  unscientific,  to  say  the  least,  to  attempt  delivery  by  either 
forceps  or  version  where  the  foetus  is  estimated  at  average  size 
and  the  tumor  narrows  the  pelvis  sufficiently  to  warrant  the 
assumption   that   delivery  Avithout   mutilation   is  problematical. 


OBSTETRIC    DYSTOCIA    AND    ITS    DETERMINATION.  33 

Aside  from  the  death  of  or  injuries  inflicted  upon  the  child  by 
attempts  at  forceps  extraction,  the  trauma  the  woman  would 
necessarily  be  subjected  to  is  a  distinct  contra-indication. 

From  this  analysis  of  the  salient  characteristics  of  deformed 
pelves  it  is  apparent  how  helpless  the  practitioner  may  be,  at  the 
term  of  gestation  or  when  labor  is  advanced,  if,  for  one  or 
another  reason,  he  has  neglected  or  it  has  been  impracticable  to 
estimate  the  capacity  of  tlie  pelvis  either  at  an  early  stage  of 
gestation  or  before  the  onset  of  labor. 

Without  the  data  obtainable  through  pelvimetry  and  ex- 
ploration of  the  pelvis,  it  is  impossible  to  elect  the  obstetric 
operation,  where  one  is  demanded,  which  best  subserves  in  a 
given  case  the  interest  of  the  two  beings  whose  safety  depends 
on  the  acquired  knowledge  and  expertness  of  the  accoucheur. 
In  practical  obstetrics,  the  forceps,  for  example,  is  too  often 
used  in  instances  where  accurate  pelvimetry  will  teach  that  it 
is  contra-indicated.  The  major  obstetric  procedures  are  too  fre- 
quently delayed  until  maternal  and  foetal  exhaustion  is  immi- 
nent or  present.  The  facts  on  which  stress  has  been  laid  teach 
the  necessity  of  deliberate  election  of  every  obstetric  operation, 
and  it  is  from  this  stand-point  that  these  operations  will  be 
considered. 


CHAPTER   II. 

ARTIFICIAL    ABORTIOX   AXD    THE    IXDUCTIOX    OF, 
PREMATURE    LABOR. 

The  term  "  abortion"'  is  applied  to  instances  where  the  ute- 
rus is  emptied  of  the  product  of  conception  either  spontaneously 
or  artificiallv  before  this  product  has  reached  that  stage  of  devel- 
opment wlieii  it  is  fitted  for  extra-uteriue  life.  Artificial  abor- 
tion, therefore,  is  performed  purely  in  the  interests  of  the  woman. 
Premature  labor,  on  the  other  hand,  when  induced,  carries  with 
it  tlie  assumption  that  the  foetus  is  capable  of  surviving  apart 
from  the  mother, — that  is  to  say,  that  this  foetus  has  reached 
wliat  is  termed  the  viable  age.  This  operation,  then,  is  resorted 
to  both  in  the  interests  of  mother  and  child,  although  ordinarily 
those  of  the  former  chiefly  urae  the  physician  to  resort  to  it. 
Tiie  induction  of  premature  labor  is.  in  general,  an  elective 
operation  ;  artificial  abortion  is  usually  forced  on  the  physician. 
The  factors  calling  for  the  one  operation  are  usually  different 
from  those  calling  for  the  other,  and  the  method  of  procedure 
also  ditfers.  It  is  useful,  therefore,  to  consider  the  subjects 
apart. 

(ti)  Artificial  Abortion. 

Tlie  diseases  and  anomalies  which  justify  artificial  abortion 
are:  1.  Advanced  pulmonary  and  cardiac  disease.  2.  The 
pernicious  vomiting  of  pregnancy.  3.  Penal  disease.  -1.  Per- 
nicious anaemia.  5.  Chorea.  6.  Absolute  pelvic  contraction 
or  occlusion  of  the  genital  tract  by  tumors,  etc.  7.  Irreducible 
displacements  of  the  uterus.  8.  Hsemorrhage  from  placenta 
prtevia.  hydatid  mole.  etc. 

Bearing  in  mind  strictly  the  fact  that  artificial  abortion  is 
performed  purely  in  the  interests  of  the  ^voman.  we  will  con- 
sider these  indications  seriatim. 

1.  Advanced  Palmonary  and  Cardiac  Disease. — At  a 
glance  it  is  apparent  what  an  untoward  effect  gestation,  if 
(34) 


ARTIFICIAL    ABORTION.  35 

allowed  to  advance,  must  have  on  the  life-limit  of  a  woman  in 
an  advanced  stage  of  phthisis  or  with  serious  cardiac  lesion. 

The  vital  force  of  the  woman  is  being  actively  expended 
in  fighting  the  disease  which  shortly  will  kill  her  when,  in 
addition,  the  extra  burden  of  supporting  foetal  growth  for  nine 
months  is  thrown  upon  her.  If  such  a  woman  be  allowed  to 
go  to  term,  even  if  she  can  withstand  the  strain  of  pregnancy 
and  of  labor,  the  duration  of  her  remnant  of  life  has  unques- 
tionably been  shortened,  and  she  will  rarely  have  the  satisfac- 
tion of  leaving  behind  her  a  healthy  babe.  Wise  and  justi- 
fiable conservatism,  therefore,  counsels  the  artificial  arrest  of 
pregnancy  as  soon  as  detected,  in  case  of  advanced  phthisis 
and  of  a  cardiac  lesion  which  has  progressed  to  the  stage  of 
dilatation. 

The  indication  may  be  said  to  be  absolute  in  the  former 
instance ;  in  the  latter  only  when  the  heart  has  begun  to  dilate, 
since  otherwise  the  physiological  cardiac  hypertrophy  of  ^Dreg- 
nancy  will  enter  as  a  compensatory  factor,  and  enable  the 
woman  to  reach  term  with  safety,  and,  likely  enough,  not 
deteriorated  in  general  health. 

2.  The  Per-nicious  Vomiting  of  Pregnancy. — This  indica- 
tion may  be  called  absolute  only  after  the  recognized  general 
and  local  remedies  have  been  tried.  Eectification  of  a  uterine 
displacement,  applications  of  solutions  of  nitrate  of  silver  to  the 
cervix,  digital  or  instrumental  dilatation  of  the  cervix,  regula- 
tion of  the  diet  and  of  the  function  of  the  intestinal  canal,  the 
internal  administration  of  drugs  (oxalate  of  cerium  in  large 
doses,  ingluvin,  minim  doses  of  ipecac  or  of  phenic  acid), — 
such,  briefly  stated,  are  the  chief  measures  on  which  depend- 
ence may  be  placed  for  the  relief  of  pernicious  vomiting.  Only 
after  such  means  have  been  tested  does  artificial  abortion  suof- 
gest  itself  as  justifiable.  It  should  then  be  deliberately  elected. 
The  physician  should  not  wait  until  the  emaciation  is  extreme, 
the  pulse  is  rapid,  and  the  fever  of  exhaustion  sets  in.  On  the 
occurrence  of  phenomena  of  exhaustion,  the  operation  may  fail 


36  OBSTETRIC     SURGERY. 

in  its  object. — the  saving  of  maternal  life, — and  generally 
emptying  of  the  uterus  is  postponed  too  late.  The  fact  that 
the  vomiting,  even  when  of  the  so-called  pernicious  type,  in 
many  instances  ceases  spontaneously  at  the  third  month, 
whilst  a  cause  for  hope,  should  never  blind  the  physician  to 
such  a  degree  as  to  lead  him  to  expectancy  oveiiong.  Whilst, 
as  a  rule,  artificial  abortion,  under  this  indication,  is  rarely 
called  for,  it  is  safer  not  to  wait  until  the  vital  forces  of  the 
woman  are  at  too  low  an  ebb. 

3.  Renal  Disease. — The  co-existence  of  renal  disease  and 
of  pregnancy  is  most  unfortunate.  Aside  from  the  strong  prob- 
ability of  the  development  of  eclampsia  if  the  pregnancy  be 
allowed  to  continue,  the  extra  wear  on  the  kidneys  associated 
with  gestation  inevitably  tends  to  shorten  the  woman's  life  if 
she  be  allowed  to  go  to  term.  This  in  particular  holds  true  of 
the  parenchymatous  form  of  nephritis.  In  a  given  case,  if 
under  absolute  milk  diet  and  the  administration  of  iron  and 
diuretics  the  amount  of  albumin  in  the  urine  do  not  decrease, 
artificial  abortion  should  be  resorted  to.  In  the  event  of  better- 
ment from  the  side  of  the  kidneys,  then,  under  constant  watch- 
fulness, the  woman  might  be  tided  over  until  tlie  child  is  viable, 
and  often  to  term. 

4.  Pernicious  Anaemia. — This  indication  will  rarely  offer 
for  the  reason  that  the  affection  is  only  exceptionally  met  with, 
and  then  conception  is  a  rarity  owing  to  the  lack  of  function  of 
the  ovaries.  In  the  event,  however,  of  pregnancy  supervening 
on  this  depraved  condition  of  the  blood,  artificial  abortion  is 
justifiable  as  soon  as  it  becomes  apparent  that  the  auEemia,  not- 
withstanding the  recognized  remedies,  is  becoming  deeper.  To 
wait  longer  is  to  aggravate  the  disease,  only  to  obtain  a  foetus 
incapable  of  extra-uterine  life. 

5.  Clwrea. — Pregnancy  has  a  deleterious  influence  on 
chorea.  In  all  the  reported  instances  the  choreic  movements 
have  become  aggravated  often  to  an  extreme  degree.  Nature 
sometimes  asserts  herself  and  abortion  is  spontaneous.     On  the 


ARTIFICIAL    ABORTION.  37 

other  hand,  it  cannot  be  positively  predicated  that  emptying  the 
uterus  will  modify  the  chorea  favorably.  The  indication,  there- 
fore, for  artificial  abortion  is  not  an  absolute  one.  The  opera- 
tion should  be  resorted  to  only  in  extreme  instances,  and  then 
only  in  the  hope  that  it  may  prove  a  remedial  measure.  Barnes's 
statistics  prove  that  gravid  choreic  women  often  die  of  the  dis- 
ease, and  that  the  foetus  rarely  survives.  It  should  further  be 
remembered  that  in  a  few  recorded  instances  chorea  associated 
with  pregnancy  has  merged  into  one  or  another  variety  of 
insanitv. 

6.  Ahsolate  Pelvic  Contraction  or  Occlusion  of  the  Genital 
Tract  by  Tumors^  etc, — By  absolute  pelvic  contraction  is  under- 
stood that  degree  of  pelvic  deformity  which  will  not  even  permit 
of  the  induction  of  premature  labor  with  viable  child.  This 
will  be  amply  considered  when  the  subject  of  premature  labor 
is  discussed.  As  soon  as  determined,  artificial  abortion  is  indi- 
cated in  order  to  save  the  woman  the  risks  of  the  alternative 
operations  at  term, — the  Csesarean  section  or  the  Porro. 

Until  the  results  from  these  operations  are  of  such  a  nature 
as  to  prove  no  greater  mortality  rates  than  that  after  abortion, 
the  duty  of  the  physician,  unless  the  woman  deliberately  elects 
the  major  operations,  is  to  empty  the  uterus.  The  same  view 
may  be  taken  of  instances  of  cicatricial  contraction  of  the  vagina 
of  such  high  degree  as  to  preclude  the  successful  induction  of 
premature  labor.  The  tumors  which  come  under  consideration, 
aside  from  exostoses,  are  fibroids  in  the  lower  uterine  segment, 
epithelioma  of  the  cervix,  impacted  ovarian  cysts.  Exostoses, 
if  sufficiently  prominent  to  occlude  the  pelvis  to  a  degree  incon- 
sistent with  the  successful  induction  of  premature  labor,  will 
always  call  for  artificial  abortion  unless,  again,  the  woman  elects 
the  Csesarean  section  at  term  ;  fibroids  in  the  lower  segment  of 
the  uterus  do  not,  as  a  rule,  interfere  with  the  development  of 
the  uterus  to  the  term  of  foetal  viability,  at  any  rate  ;  but  at  this 
date,  and  later,  the  choice  will  necessarily  lie  between  enuclea- 
tion of  the  fibroid  per  vaghiam  before  delivery  can  be  effected 


38  OBSTETRIC     SURGERY. 

or  else  the  Csesarean  section  or  the  Porro.  Enucleation  of  a 
fibroid  by  the  vagina  is  at  best  a  formidable  operation,  and  be- 
comes all  the  more  so  in  the  presence  of  the  vascularity  asso- 
ciated with  pregnancy.  To  say  nothing  of  the  risk  of  septi- 
c£emia  during  the  puerperium,  the  safety  of  the  woman  is  best 
subserved  by  emptying  the  uterus  at  an  early  stage,  unless,  again, 
in  full  view  of  its  risks,  she  elects  the  alternative  operations  at 
term.  It  is  understood,  of  course,  that  an  ovarian  cyst  impacted 
in  the  pelvis  cannot  be  removed  through  abdominal  section 
without  first  emptying  the  uterus ;  therefore,  the  proper  course 
to  pursue  is  to  induce  abortion,  and  at  one  and  the  same  time  to 
remove  the  cyst  by  one  or  another  of  the  recognized  methods. 
Epithelioma  of  the  uterus,  whenever  discovered,  should  be  re- 
moved either  by  high  amputation  or  by  vaginal  hysterectomy. 
In  either  event  the  gestation  will  be  interrupted  ;  so  that  artificial 
abortion  is  forced  on  the  physician,  and  not  elected.  Advanced 
carcinoma  of  the  lower  uterine  segment,  when  complicated  by 
pregnancy,  becomes  all  the  more  serious  the  longer  the  gestation 
is  allowed  to  continue.  The  chief  risk  the  woman  runs  is  that 
from  sudden  profuse  hsemorrhage ;  but,  seeing  that  the  woman 
may  be  made  more  comfortable  by  a  partial  operation,  this 
should  be  resorted  to  even  though  it  interrupt  gestation.  At 
term  delivery  per  vias  naturaJes  might  be  possible  without  fatal 
result  to  the  woman ;  but  this  being  problematical,  active  inter- 
ference is  justifiable  before  the  child  is  viable,-  Fortunately 
women  with  advanced  carcinoma  rarely  conceive. 

It  is  a  recognized  surgical  rule,  to-day,  to  remove  an 
ovarian  cyst  as  soon  as  it  is  discovered.  If  pregnancy  co-exist, 
ovariotomy  may  be  performed  and  the  gestation  not  interrupted. 
This  is  exceptional  in  the  favorable  case,  when  the  tumor  is 
not  impacted  in  the  pelvis.  In  the  latter  instance  the  maternal 
chances  are  better  if  the  uterus  be  first  emptied  lege  arils,  and 
the  ovariotomy  be  performed  afterward.  Obviously  the  phy- 
sician should  be  on  his  guard  lest,  during  the  process  of  abor- 
tion, the  cyst  rupture.     Puncture  of  the  cyst  by  the  vagina  as 


ARTIFICIAL    ABORTION.  39 

an  elective  measure  cannot  too  strongly  be  condemned.  Whilst 
such  a  measure  will  diminish  the  size  of  the  tumor,  and  thus, 
perhaps,  enable  the  gestation  to  advance  nearly  or  to  term,  with 
resulting-  viable  foetus,  puncture,  however  aseptically  performed, 
carries  with  it  the  risk  of  suppuration  of  the  cyst,  in  which 
event  neither  abortion  nor  ovariotomy  might  avail  to  save  the 
woman.  Obviously,  where  the  obstructing  tumors  are  so  large 
as  to  interfere  with  access  to  the  uterine  cavity,  it  ceases  to  be  a 
question  of  even  artificial  abortion,  and  the  physician  is  called 
upon  to  decide  upon  the  relative  risks  of  interference  surgically 
with  the  tumor  before  or  at  term.  Where  the  risk  is  equal 
the  latter  period  should,  of  course,  be  selected,  since  the  child 
is  then  given  a  chance. 

7.  Irreducible  Displacements  of  the  Uterus. — No  displace- 
ment of  tlie  uterus  uncomplicated  by  adhesions  must  be  con- 
sidered irreducible  so  as  to  require  artificial  abortion  until 
replacement  under  auEesthesia,  with  the  woman  in  the  knee- 
chest  position,  has  failed.  Simpler  metliods  are,  of  course,  first 
to  be  tested.  Impaction  of  the  gravid  uterus  below  the  promon- 
tory of  the  sacrum  may  simulate  an  adherent  uterus  ;  but  if  the 
Avoman  assume  the  knee-chest  position  and  the  cervix  be  drawn 
downward  by  means  of  a  tenaculum  inserted  into  the  anterior 
lip,  reposition  may,  as  a  rule,  be  effected  if  the  displacement  be 
uncomplicated.  In  an  instance  of  this  nature,  if  seen  before 
tlie  third  month,  emptying-  of  the  uterus  will  rarely  be  called 
for.  It  is  the  adherent  fundus  which  generally  will  give  rise  to 
trouble.  Unquestionably,  in  many  of  these  instances,  the  adhe- 
sions stretch  and  enable  the  uterus  to  rise  above  the  brim  ;  but 
where  this  does  not  occur,  gentle  attempts  at  manual  stretching 
of  the  adhesions  having  failed,  artificial  abortion  should  be 
resorted  to  before  the  uterus,  developing  asymmetrically, — in 
case  spontaneous  abortion  do  not  occur, — causes  grave  symp- 
toms from  the  side  of  the  bladder,  possibly  leading  to  rupture 
of  the  organ. 

8.  Hcemorrliage. — The  slight  discharge  of  blood  which  not 


40  OBSTETRIC     SURGERY. 

uncommonly  complicates  the  early  months  of  pregnancy  will 
never  call  for  artificial  abortion.  Rest  in  bed  with  appropriate 
remedies — such  as  the  viburnum  prunifolium  and,  perhaps,  an 
opiate ;  removal  of  the  cause,  such  as  a  small  submucous 
polyp — will,  as  a  rule,  suffice  to  check  what  at  times  is  simply 
an  attempt  at  periodical  menstruation.  It  is  the  haemorrhage 
met  with  between  the  third  and  sixth  months  of  gestation  which 
may  warrant  abortion.  Haemorrhage  at  this  period  should 
always  suggest  a  low  attachment  of  the  placenta,  and,  when 
profuse  enough  to  threaten  maternal  exhaustion,  it  is  conserva- 
tive to  empty  the  uterus  rather  than  to  endeavor  to  tide  over 
the  patient  until  the  foetus  has  attained  viability. 

Such,  briefly  outlined,  are  the  complications  of  early  preg- 
nancy which  chiefly  will  call  for  artificial  abortion.  This  oper- 
ation should  never  be  determined  upon  without  the  advice  of 
a  consultant.  The  risk  to  the  woman  where  the  operation  is 
carefully  performed  is  slight,  presumably  always  slighter  than 
that  she  is  subject  to  if  the  gestation  be  not  interrupted ;  but 
no  physician,  except  in  strict  emergency,  should  induce  an 
abortion  without  the  support  of  one  or  more  consultants.  He 
will  thus  be  amply  protected  against  scandal  and  legal  process, 
should  either  arise. 

In  view  of  the  fact  that  artificial  abortion  is  an  operation 
which  is  forced  upon  the  physician,  when  the  indication  presents, 
the  object  is  to  empty  the  uterus  as  rapidly  as  is  consistent  with 
the  welfare  of  the  woman.  The  method  of  procedure  about  to 
be  described  is  peculiarly  applicable  to  gestation  which  has  not 
advanced  beyond  the  third  month.  After  this  period,  the 
foetus  and  its  adnexa  being  larger,  and  fuller  dilatation  of  the 
cervical  canal  being  therefore  requisite,  the  metliod  to  be  de- 
scribed under  the  subject  of  the  induction  of  premature  labor 
is  to  be  selected. 

The  administration  of  so-called  abortifacients  and  resort  to 
electricity  are  proposed  methods  for  the  induction  of  abor- 
tion which  are  so  problematical  in  their  results  as  not  to  be 


ARTIFICIAL    ABORTION. 


41 


worthy  of  trial.  Tamponing  the  vagina,  associated  with  the 
administration  of  ergot,  was  a  method  formerly  greatly  in  vogue. 
It  should  be  rejected,  however,  because  it  is  slow  in  action,  un- 
certain in  its  results,  and  difficult  to  maintain  aseptically.  The 
sponge  tent  for  dilating  the  cervix  cannot  be  too  strongly  con- 
demned, on  the  ground  that  the  chances  of  sepsis  following  its 
use  are  very  great.  It  should  ever  be  borne  in  mind  that  the 
operation  is  performed  in  the  interest  of  the  woman,  and  that 
the  one  risk  the  physician  subjects  her  to  is  sepsis. 

OPERATION    FOR    THE    INDUCTION    OF    ABORTION. 

The   instruments   strictly  requisite  are :   A  steel-branched 
uterine  dilator,  a  uterine  dull  curette,  an  ovum  forceps,  an  intra- 


Fig.  20.— Steel-branched  Dilator. 


uterine  irrigating  tube,  the  finger.      These  instruments  should 
be  carefully  sterilized. 

The   intestinal    canal    should  be    thoroughly  emptied    by 
enema,  and  the  bladder  by  catheter.      The  external  genitals  and 


Fio;.  21.— Uterine  Curette. 


the  vagina  must  be  thoroughly  asepticized.  Douching  will  not 
accomplish  this.  Both  the  genitals  and  the  vagina  .'^hould 
be  scrubbed  with  soap  and  water,  and  then  washed  with  a 
2-per-cent.    solution   of    creolin    or   a    1    to    5000    solution   of 


42 


OBSTETRIC     SURGERY, 


bichloride  of  mercury.  Thus  alone  may  the  rugosities  of  the 
vagiua  be  rendered  aseptic.  If  the  operator  prefer  continuous 
irrigation  during  Ins  manipulations  tlie  creolin  solution  answers 


Fig.  22. — OTTim  Forceps. 


admirably,  since  it  will  not  injure  the  instruments  and  will  not 
poison  the  patient.  The  liands  of  the  operator  and  of  his  assist- 
ant should  be   scrupulously  scrubbed  with  soap  and  Avater,  and 


Fig.  23.— Glass  Irrigating  Tube. 


then  carefully  washed  in  a  solution  of  bichloride  of  mercury. 
These  details  are  called  ibr  in  order  to  avoid  septic  infection  of 
the  patient. — the  risk,  we  would  repeat,  which  the  woman  is 


Fig.  24. — Fritsch-Bozemau  Catheter. 


subjected  to.  As  a  rule,  it  is  desirable  to  anaesthetize  the 
patient.  The  operation,  when  resorted  to  at  alh  must  he 
thorough,  and  it  is  difficult  to  secure  this  if  the  patient  be 
struggling  and  complaining.      The  patient  is  placed  upon  the 


ARTIFICIAL    ABORTION. 


43 


table  in  the  lett  lateral  or  dorsal  position,  according  to  the 
preference  of  the  operator.  We  prefer  the  dorsal  position 
because  all  the  necessary  steps  are  best  followed  in  this  position, 
and  because,  furthermore,  the  uterus  is  under  better  control. 


Fig.  25. — Edebolil's  Speculum. 


A  speculum  is  inserted  into  the  vagina,  and,  the  cervix  having 
been  exposed,  a  tenaculum  is  inserted  into  the  anterior  cervical 
lip  to  steady  the  uterus. 

The  steel  dilator  is  passed  into  the  cervix  beyond  the  in- 


Fig.  26.— Cervical  Tenaculum. 

ternal  os,  and  the  canal  is  slowly  stretched  to  the  extent  of  an 
inch  and  a  half  to  two  inches.  The  cervical  muscle  is  made  to 
yield  to  the  applied  pressure;  the  aim  is  not  to  rupture  the 
cervix.     Owing  to  the  hypersemia  and  softening  of  the  cervix, 


44  OBSTETRIC     SURGERY. 

which,  as  a  rule,  is  present  even  in  the  early  months  of  preg- 
nancy, dilatation  to  this  extent  will  ordinarily  be  possible.  The 
instruments  are  then  to  be  removed,  and  the  next  step  is  the 
extraction  of  the  ovum. 

The  best  of  all  instruments  for  the  loosening  of  the  ovum, 
the  breaking  up  of  the  foetus,  and  for  the  removal  of  the  debris 
is  the  aseptic  finger.  It  is  sentient,  and  therefore  it  is  less  likely 
to  do  harm  than  any  instrument.  We  are  operating  to  protect 
the  interests  of  the  woman,  and,  therefore,  must  take  every  pre- 
caution to  see  that  these  interests  are  not  endangered.  In  the 
average  case  of  abortion  under  the  third  month  it  is  possible  to 
empty  the  uterus  by  the  finger  alone,  provided  the  physician 
proceeds  as  follows  :  The  woman  should  be  anaesthetized.  The 
fundus  of  the  uterus  is  grasped  through  the  abdominal  wall, 
and  the  organ  is  depressed  deeply  into  the  pelvic  cavity  in  the 
axis  of  the  inferior  strait.  The  other  hand  is  introduced  into 
the  vagina,  and  the  index  finger  is  inserted  to  the  fundus  of  the 
uterus,  slowly,  in  order  to  obtain  greater  dilatation  than  has  fol- 
lowed the  use  of  the  dilator.  The  ovum  is  then  carefully 
pealed  from  its  connection  with  the  uterus.  Up  to  the  second 
month  of  gestation  it  may  ordinarily  be  removed  in  its  entirety. 
Beyond  this  period  it  is  usually  necessary  to  break  up  the  ovum 
by  the  intra-uterine  finger,  and  this  may  be  accomplished  with- 
out great  difficulty,  provided  the  external  hand  firmly  controls 
and  steadies  the  uterus. 

In  instances  where  it  is  not  possible  to  depress  the  uterus 
sufficiently  to  enable  the  finger  (the  hand  being  in  the  vagina) 
to  reach  the  site  of  the  ovum,  the  long  uterine  curette  takes  the 
place  of  the  finger.  The  instrument,  however,  should  be  used 
simply  to  loosen  the  connection  of  the  ovum  with  the  uterus, 
the  after-extraction  being  accomplished  either  by  means  of  the 
ovum-forceps  or  by  the  finger.  The  manipulation  is  as  fol- 
lows: The  curette  seeks  to  penetrate  between  the  ovum  and 
the  uterine  wall,  the  external  hand  being  conscious  of  and  tlius 
indirectly  controlling  the  action  of  the  instrument.     When  dis- 


ARTIFICIAL    ABORTION. 


45 


lodged  in  this  manner,  if  the  finger  cannot  complete  removal, 
the  ovum-forceps  should  be  used  to  grasp  and  to  extract  it. 

The  haemorrhage  from  these  manipulations  is,  as  a  rule, 
considerable,  but  the  external  hand  grasping  the  uterus  may 
soon  cause  efficient  contraction.  When  satisfied  that  the  uterus 
has  been  thoroughly  emptied,  a  |-drachm  of  ergot  or  10  minims 
of  ergotole  should  be  injected  into  the  nates,  the  intra-uterine 
tube  should  be  inserted  into  the  cavity  of  the  uterus  and  the 
organ  washed  out  either  with  a  1  to  5000  solution  of  bichloride 
of  mercury  or  with  a  3-per-cent.  solution  of  creolin.  The  last 
step,  and  we  believe  a  most  important  step,  is  the  insertion  to 
the  fundus  of  a  sterilized-gauze  drain. 

The  object  of  this  drain  is  twofold :  At  times,  owing  to 


Fig.  27.— Intra-uterine  Dressing  Forceps. 

flexion  at  the  level  of  the  internal  ,os,  drainage  from  the  uterine 
cavity  is  imperfect  and  the  retained  secretions  might  give  rise  to 
septic  symptoms ;  furthermore,  no  matter  how  exact  our  asepsis, 
an  error  in  technique  may  creep  in,  and,  if  local  sepsis  should 
develop,  we  want  above  all  things  free  external  drainage,  in  order 
to  avoid,  as  far  as  is  possible,  extension  to  the  Fallopian  tubes. 
This  drain,  therefore,  is  prophylactic  in  its  aim.  It  can  do  no 
harm,  and  it  may  be  the  means  of  preventing  serious  damage. 

The  steps  detailed  will  answer  for  the  induction  of  abortion 
and  lor  its  completion  in  the  average  case  under  the  fourth 
month.  Occasionally,  however,  the  cervix  is  rigid,  and  then 
the  steel-branched  dilator  and  the  finger  cannot  secure  ample- 
enough  dilatation.     In  such  an  event  many  practitioners  resort 


4:6  OBSTETRIC     SURGERY. 

to  t'ry.t- :  '"U":  for  t'le  rea-o::  already  stated  and  again  emphasized, 
t:.:;-  :':,-  -py„_^i-  r-ri"::  cliI.i.o:  "ue  rendered  aseptic,  we  emphatically 
cc;.u-i:;:.  ::.:-  a_-i.:  ;  :i:cj,;Ji:-i;  as  well  all  other  terms  of  tent), 
and  we  c-:-.;-.  :.d  the  following  procedure  :  The  external  geni- 
tr,"^  ■:.  ^.  ::^::  v  _::.m  having  been  rendered  aseptic  in  the  manner 
w.^-  ■:.::\ :,  awtj.t  upuu,  the  cer^dx  is  exposed  through  a  speculum 
aid  -:r.uiied  by  a  tenaculum.  As  much  dilatation  as  possible 
is  secured  by  the  steel-branched  dilator,  and  then  the  cervical 
canal  and  the  lower  ur:  r:  -meut  is  packed  by  means  of  the 

intra-uterine  dressing  ibrcep-  vir^i  sterihzed  gauze.  At  the  end 
of  from  six  to  eight  hours  tL-  _a  ize  may  be  removed,  when,  as 
a  rule,  the  cervical  canal  will  be  found  sufficiently  patulous  for 
the  finsrer  or  else  the  cervical  tissues  have  been  sufficiently 
softened  by  the  gauze  to  enable  the  steel-branched  dilator  to 
act  efficiently.  The  further  steps  are  similar  to  those  already 
detailed. 

There  remain  for  consideration  those  instances  where  the 
cervical  canal  is  not  accessible  to  the  dilator,  owing,  as  a  rule, 
to  the  marked  retroversion  of  the  uterus  with  or  without  ad- 
hesions. It  has  been  recommended,  in  such  instances,  to  punct- 
ure the  uterus  through  the  rectum,  the  object  being  to  tap  the 
amniotic  sac,  which  procedure  will  result  in  spontaneous  abor- 
tion. This  method  should  never  be  resorted  to,  owing  to  the 
absolute  certain tv  of  canwiiio-  pjroducts  of  infection  into  the 
uterus.  The  recturn  canr.ot  be  aseptir^ized  as  may  the  vagina. 
The  aim  of  the  method  Avill  be  as  well  subserved  by  tapping 
through  the  vasfina.  car-  h-::.2^  taken  to  avoid  any  large  vessels 
and  al-'>  ^'■..■:  ure>tral  triai;-le.  Very  rarely  will  such  a  step  be 
nece—  : '  .  :.  .''v.r\>:^i-.  and  if  resorted  to  the  method  must  be  called 
an  u.:.:-:-.:  ::.  -  ae.  In  the  face  of  an  emercrency  suggesting  it, 
it  is  wise  to  wei2"h  the  alternative  step. — abdominal  section,  the 
breaitiai^  up  of  trie  adhesions,  and  reposition.  2>^/'  o.hdorninem. 
of  the  'i':e:u-. 

Artihcial  abortion,  if  performed  aseptically.  and  if  elected 
before  the  woman  is  at  too  low  an   ehb  from  tlie  affection  indi- 


INDUCTION  OF  PREMATUEE  LABOR.  47 

eating  the  operation,  ought  not  to  have  a  mortahty  rate. 
Haemorrhage  we  may  control ;  sepsis  is  avoidable  by  the  steps 
of  the  operation  we  have  advocated ;  shock  need  be  feared  only 
when  the  physician  sees  the  patient  too  late  or  trusts  to  expect- 
ancy overlong.  The  after-treatment  of  cases  where  the  phy- 
sician has  been  called  upon  to  induce  abortion  is  similar  to  that 
which  is  applicable  to  the  puerperium  after  delivery  at  term. 
The  woman  should  remain  in  bed  for  about  a  week,  not  neces- 
sarily in  the  recumbent  position,  however.  If  there  be  no 
contra-indication  from  the  side  of  the  heart,  and  if  the  disease 
which  called  for  the  induction  of  abortion  will  permit,  it  is  de- 
cidedly advantageous  for  the  patient  to  sit  up  in  bed  according 
to  her  fancy,  for  thus  the  vagina  drains  to  better  advantage. 

If  the  operation  has  been  performed  aseptically,  there  will 
be  no  call  for  either  vaginal  or  intra-uterine  douching.  Where 
a  gauze  drain  has  been  inserted  into  the  uterine  cavity,  it  may 
be  removed  at  the  end  of  sixty  hours ;  and  if  there  be  no  evi- 
dence of  local  sepsis,  it  need  not  be  re-inserted.  If,  notwith- 
standing all  our  aseptic  precautions,  sepsis  develop,  its  surgical 
treatment  will  be  in  accordance  with  the  rules  to  be  emphasized 
in  the  chapter  dealing  with  the  surgery  of  the  pathological 
puerperium. 

(h)  The  Induction  of  Premature  Labor. 

Obviously,  the  indications  for  the  induction  of  abortion 
hold  with  equal,  if  not  greater,  stringency  in  case  of  the  induc- 
tion of  premature  labor.  The  object  to  be  attained,  however, 
is  twofold.  Both  the  interests  of  the  foetus  and  of  the  woman 
are  to  be  considered.  Exceptionally,  as  will  be  noted,  those 
of  the  former  alone  call  for  the  operation.  From  the  side  of 
both  the  woman  and  of  the  child,  the  chief  indications  for  the 
induction  of  premature  labor  are:  1.  Contracted  pelves^.  2, 
Haemorrhage.     3.   Eclampsia. 

From  the  stand-point  of  the  child  alone  the  indication 
offers  where,  in  a  previous  labor,  the  foetus  has   died  a  short 


48  OBSTETRIC     SURGERY. 

time  before  term  as  a  result,  frequently,  of  disease  of  the  pla- 
centa, sucli  as  fatty  degeneration.  Here,  by  electing  premature 
labor  in  a  succeeding  pregnancy  a  few  weeks  before  term,  at  a 
period  when,  from  the  decrease  in  fcetal  movements,  it  may  be 
inferred  that  death  is  imminent,  the  physician  may  succeed  in 
obtainino-  a  livin"-  child. 

1.  Induction  of  Premature  Labor  in  Case  of  Deformity 
of  the  Pelvis. — Deformity  of  the  pelvis  of  varying  grade  is  by 
far  the  most  frequent  indication  for  the  induction  of  premature 
labor.  The  aim  is  a  most  beneficent  one,  seeing  that  the  major 
obstetrical  operations — the  Caesarean  section,  symphysiotomy, 
and  embryotomy — are  thus  often  avoided.  As  Robert  Barnes, 
with  a  certain  amount  of  truth,  puts  it,  spontaneous  labor  may 
supersede  the  forceps,  the  forceps  may  supersede  version,  version 
craniotomy,  and  the  Csesarean  section  may  be  eliminated. 
Whether  it  is  desirable  or  not  tliat  craniotomy  sliould  supersede 
the  Csesarean  section  will  be  considered  later,  as  also  the  effect 
of  the  resuscitation  of  symphysiotomy. 

In  the  instances  under  consideration,  the  problem  for  the 
physician  to  solve  is  most  complex.  He  must  determine  as 
accurately  as  possible  the  term  of  gestation,  in  order  to  speak 
with  any  degree  of  authority  in  regard  to  the  chances  of  viability 
of  the  child.  He  must  estimate  the  probable  size  of  the  foetus 
in  relation  to  the  degree  of  pelvic  contraction  in  a  given  case. 
He  must  bear  in  mind  the  degree  of  molding  'to  which  the 
diameters  of  the  foetal  head  are  susceptible  within  safe  limits. 
He  must,  lastly,  ever  be  conscious  of  the  fact  that  in  deferring 
the  operation  overlong  in  the  interest  of  the  child  he  may  be 
increasing  the  risks  which  the  woman  runs.  It  is  thus  apparent 
how  difficult  it  is  to  select  just  the  right  time  for  the  induction 
of  premature  labor  from  an  elective  stand-point. 

The  determination  of  the  stage  of  gestation  so  as  to  insure 
fcetal  viability  is  not  a  simple  matter.  In  almost  every  instance 
there  is  likely  to  be  a  margin  in  error  of  at  least  a  fortnight. 
Where  the  exact  date  of  the  cessation  of  menstruation  can  be 


INDUCTION  OF  PREMATURE  LABOR.  49 

ascertained,  the  rule  of  adding  seven  days  and  counting  buck 
three  months,  in  order  to  approximate  the  term  of  gestation,  is 
exact  enough  only  in  the  lesser  grades  of  pelvic  deformity;  for 
here,  if  the  error  of  a  fortnight  creep  in,  at  best  the  child  has 
not  passed  the  seven  and  a  half  months  of  gestation.  Where 
the  interests  of  the  child,  on  the  other  hand,  demand  the  induc- 
tion of  premature  labor  at  the  seventh  month,  at  least,  the 
difficulty  in  determining  this  date  might  lead  us  to  resort  to  the 
operation  before  the  term  of  viability  or  else  beyond  it,  when, 
in  either  event,  the  operation,  so  far  as  the  child  were  concerned, 
would  be  a  failure.  The  two  hundred  and  twentieth  day  of 
gestation  may  be  taken  as  the  lowest  limit  when,  with  the 
improved  means  at  our  disposal  (the  coiiveiise,  or  incubator),  a 
chance  of  the  child  being  reared  exists.  Error  in  our  data 
below  this  period  may  be  taken  as  being  fatal  to  the  child.  Not 
only,  therefore,  is  it  essential  to  obtain  as  accurately  as  possible 
the  date  of  the  cessation  of  the  last  menstruation,  but  also  that 
of  quickening.  The  first  sensation  of  foetal  motion  occurs  from 
three  to  three  and  a  half  months  after  conception,  in  some  cases 
not  till  the  fourth  month.  Here,  again,  is  a  chance  of  error  of 
a  fortnight.  But,  by  weighing  the  probable  date  of  conception 
against  the  date  of  perception  of  foetal  motion  and  comparing 
this  with  the  height  of  the  uterus  above  the  pelvic  brim,  the 
physician  is,  at  any  rate,  unlikely  to  err  against  the  term  of 
viability.  It  will  be  remembered,  of  course,  that  the  general 
statement  of  the  height  of  the  uterus  at  various  stages  of  gesta- 
tion is  subject  to  modification  in  the  presence  of  a  contracted 
pelvis.  Whilst,  normally,  the  fundus  of  the  uterus  is  on  a 
level  with  the  umbilicus  at  the  sixth  month  of  gestation,  and 
about  two  fingers'  breadth  above  this  at  the  seventh  month, 
in  case  of  contraction  chiefly  at  the  pelvic  brim  these  relative 
situations  will  be  a  trifle  higher.  Thus,  at  the  sixth  month  the 
fundus  may  occupy  the  position  which  normally  it  would  at  the 
seventh. 

Having  determined  as  accurately  as  possible  the  date  of 


50 


OBSTETRIC     SURGERY. 


conception,  the  next  factor  is  the  estimation  of  the  size  of  the 
foetus  wliich  must  pass  through  the  given  contracted  pelvis. 
The  size  of  the  foetus  can,  of  course,  only  be  relatively  estimated. 
The  best  guide  at  our  disposal  is  that  furnished  by  Ahlfeld,  and 
the  value  of  this  guide  at  best  is  very  limited.  From  extended 
study,  Ahlfeld  concluded  that  the  long  axis  of  the  foetus  lying 
flexed  in  the  uterus  is  nearlv  half  the  entire  leno-th  of  the  foetus 
when  extended.  To  determine  the  axis  in  utero  of  the  foetus, 
one  arm  of  a  pelvimeter  is  placed  in  the  vagina  in  contact  with 
the  foetal  presenting  part,  and  the  other  arm  is  placed  on  the 
abdomen  at  the  site  of  the  fundus  over  the  other  end  of  the 
foetus.  Multiplying  the  obtained  measurement  by  two,  the 
total  length  of  the  fcetus  is  obtained.  According  to  Ahlfeld, 
the  length  of  the  extended  foetus  bears  a  certain  definite  relation 
to  the  period  of  gestation.  Thus:  From  the  38th  to  the  -IrOth 
week  of  gestation  the  length  of  the  intra-uterine  foetal  axis 
varies  from  9|  inches  to  10.  The  total  length  of  the  fcetus, 
therefore,  is  about  20  inches.  From  the  35th  to  the  38th  week 
the  intra-uterine  axis  varies  between  8|  and  9|  inches.  The 
length  of  the  fcetus  is  18 J  to  19  J  inches.  From  the  30th  to  the 
35th  week  the  intra-uterine  length  varies  from  Si  to  8f  inches, 
and  the  total  length  of  the  foetus  is  16  to  18  inches.  From  the 
25th  to  the  30th  week  the  intra-uterine  length  varies  from  7  to 
8i  inches,  and  the  mean  total  lengtli  of  the  foetus  is  about  15 
inches. 

Ahlfeld  further  determined  that  this  length' of  the  foetus 
stood  in  the  follo^vino■  relation  to  the  weia-ht: — 


Weight. 

Length. 

At  the  40th  week,     .         .         -61  pounds. 

19-^  inches 

At  the  38tli  Tveek, 

6|-  pounds. 

19^  inclies 

At  the  .36th  ^veek, 

6;^  pounds. 

18| inches 

At  the  35th  week, 

6     pounds. 

]Ti  inches 

At  the  34th  week, 

5^  pounds. 

17^  inches 

At  the  33d  week. 

4i  pounds. 

16| inches 

At  the  80th  week. 

4^  pounds. 

16^  inches 

At  the  28th  week. 

3^  pounds. 

15| inches 

INDUCTION    OF    PREMATURE    LABOR.  51 

The  data  furnished  by  tliese  researches  of  Ahlfeld,  whilst 
only  of  approximate  value  in  estimating  the  size  of  the  foetus, 
are  still  of  great  assistance  in  determining  tlie  period  at  which 
labor  should  be  induced.  An  important  factor  lacking,  how- 
ever, is  the  average  size  of  the  foetal  head  at  various  stages  of 
gestation.  The  diameter  of  the  foetal  head  of  the  greatest  im- 
portance is  the  biparietal.  As  the  result  of  many  measure- 
ments made  by  Budin,  Tarnier,  Stolz,  and  others,  the  average 
length  of  this  diameter  at  various  stages  of  gestation  is:  at 
term,  about  31  inches ;  at  8J  months,  about  3.-i  inches ;  at  8 
months,  about  3.2  inches;  at  7J  months,  about  2.96  inches;  at 
7  months,  about  2.75  inches. 

The  foetal  head,  further,  may  be  safely  compressed  to  the 
extent  of  about  0.4  inch.  Remembering'  this  de^rree  of  safe 
compressibility,  having  estimated  the  size  of  the  foetus  and  the 
stage  of  gestation,  the  next  important  element  in  the  problem 
is  the  determination  of  the  degree  of  pelvic  deformity  present. 
Before  passing,  however,  to  renewed  reference  to  this,  we  will 
state  the  method  of  estimating  the  adaptability  of  the  foetal 
presenting  part  to  tlie  pelvic  canal  which  answers  every  pur- 
pose for  private  practice,  and  which  commends  itself,  also,  on 
account  of  its  simplicity. 

As  long  as  the  foetal  presenting  part  can  enter  the  pelvic 
brim,  obviously  the  time  for  the  induction  of  premature  labor 
may  be  deferred ;  but  just  as  soon  as  the  presenting  part, 
engages  with  difficulty,  the  time  is  ripe  for  interference. 

Every  week,  therefore,  the  physician  should  examine  his 
patient  for  the  purpose  of  determining  the  above  fact.  Intro- 
ducing one  or  more  fingers  into  the  vagina,  he  presses  the  fundus 
of  the  uterus  downward  in  the  axis  of  the  pelvic  inlet  and  the 
fingers  in  the  vagina  are  able  to  appreciate  the  ease  with  which 
the  presenting  part  adapts  itself  to  the  pelvic  brim.  If  need  be, 
the  patient  should  be  examined  under  anaesthesia.  (See  Fig.  2, 
Plate  III.) 

By  reference  to  Chapter  I  the  method  of  determining  the 


52  OBSTETRIC     SURGERY. 

pelvic  diameters  and  the  characteristics  of  the  chief  varieties  of 
pelvic  contraction  will  be  recalled.  Taking  the  length  of  the 
conjugate  of  the  brim  as  our  guide,  seeing  that  it  is  the  in- 
ternal diameter  of  the  pelvis  which  alone  can  be  determined 
with  any  degree  of  accuracy,  and  remembering  that  in  a  given 
case  tlie  capacity  of  the  pelvis  may  be  approximately  estimated 
best  by  examination  by  the  entire  hand  under  anaesthesia,  we 
may,  with  Charpen tier,  formulate  the  following  general  rules, 
which  are  the  result  of  an  extended  study  of  the  reports  of 
numerous  maternities  and  clinics  : — 

If  the  conjugate  is  at  least  3  J  inches,  the  biparietal  diameter 
of  the  foetal  head  at  term  being  of  inches  (compressible  to  the 
extent  of  about  0.4  inch),  then,  in  multiparse,  labor  should  be 
induced  between  8J  to  81  months,  according  to  the  estimated 
size  of  the  foetus  and  the  difficulty  in  delivery  offered  by  former 
labors.  In  primiparse,  since,  in  general,  the  child  is  smaller,  it 
is  safe  to  wait  till  a  week  before  term.  Where  the  conjugate  is 
3.35  inches  premature  labor,  both  in  the  multipara  and  in  the 
primipara,  should  be  induced  at  8  to  8|  months.  Where  the 
conjugate  is  3.12  inches,  labor  is  to  be  induced  between  8  and 
8|  months  at  least.  AYhere  the  conjugate  is  2.95  inches,  labor 
is  to  be  induced  between  7J  and  8  months.  Where  the  con- 
jugate is  2.75  inches,  labor  is  to  be  induced  between  7  months 
and  7  months  and  3  weeks.  Where  the  conjugate  is  2|  to  2.36 
inches,  labor  must  be  induced  as  near  the  seventh  month  as 
practicable,  and  certainly  no  later  than  11  months.  Below  2.36 
inches  tlie  indication  for  the  induction  of  premature  labor  does 
not  exist.  To  resort  to  it  would  necessarily  entail  an  embry- 
otomy, and  this  carries  risk  to  the  mother  and  subserves  not 
the  child.  At  this  point,  then,  the  indication  for  artificial  abor- 
tion in  contracted  pelves  begins. 

It  is  to  be  remembered  that  the  figures  just  given  hold  good 
only  for  the  foetus  estimated  to  be  of  the  average  size,  and  for  a 
pelvis  which  ranks  under  the  flat  type  or,  possibly,  the  generally 
contracted  type.     The  prognosis  for  the  child  is  better,  under 


INDUCTION  OF  PREMATURE  LABOR.  53 

the  measurements  given,  if  the  pelvis  be  of  the  former  variety 
than  if  it  be  of  the  latter.  In  general,  of  course,  the  special 
type  of  pelvis  will  alter  the  indication.  All  that  we  aim  to  do 
here  is  to  state  the  general  indications  which  serve  as  guides  in 
the  election  of  the  period  at  which  premature  labor  should  be 
induced  in  the  face  of  pelvic  deformity.  It  is  impossible  to  lay 
down  special  rules,  since  each  case  must  be  studied  from  its 
special  stand-point. 

2.  Hcemorrhage  as  an  Indication  for  the  Induction  of  Pre- 
mature Lcd)or. — Haemorrhage  occurring  after  the  fourth  month 
of  gestation  should  always  awaken  the  suspicion  of  placenta 
prsevia.  There  is  little  agreement  amongst  obstetrical  writers  as 
to  the  advisability  of  inducing  premature  labor  on  the  appear- 
ance of  the  first  hsemorrhage  due  to  faulty  implantation  of  the 
placenta.  A  careful  study  of  this  question,  in  the  light  chiefly 
of  the  mo  e  modern  statistical  data,  warrants  the  following  state- 
ments, which  assist  in  reaching  a  conclusion  sound  in  practice, 
seeing  that  it  takes  account  of  the  interests  both  of  the  woman 
and  the  child.  As  has  been  noted  under  the  subject  of  artificial 
abortion,  in  rare  instances  the  hgemorrhage  due  to  faulty  insertion 
of  the  placenta  occurs  as  early  as  the  fifth  month  of  gestation. 
As  a  rule,  however,  it  is  within  the  six  weeks  preceding  term 
that  hsemorrhage  appears.  Usually  the  first  haemorrhage  is  not 
profuse  enough  to  endanger  either  the  woman  or  the  child.  It 
may  be  taken,  however,  as  nature's  danger  signal,  warning  the 
alert  physician  that  a  second  hsemorrhage  may  at  any  time  occur, 
and  in  such  amount  that  not  alone  will  the  child  probably  die 
before  delivery,  but  that  the  woman  as  well  will  be  seriously  en- 
dangered. Instances  of  this  nature  are  extreme  ones,  but  in  no 
given  case  can  it  be  predicted  that  such  will  not  be  the  issue 
of  the  second  hsemorrhage.  Unquestionably,  through  enforced 
rest  in  bed,  the  woman  may  often  be  tided  to  term  and  deliver}'- 
be  safely  accomplished  for  the  child  as  well  as  for  the  woman  ; 
but  even  during  rest  in  bed  profuse  hsemorrhage  may  occur,  and 
this  too  at  a  time  when  the  physician  may  not  be  in  ready  reach 


54:  OBSTETRIC     SURGERY. 

of  the  woman.  All  authorities  are  agreed  that  the  excessive  ma- 
ternal mortality  of  the  past  was  due,  in  part,  to  faulty  methods 
of  treatment,  in  part  to  delay  in  resort  to  active  measures.  The 
maternal  mortality  has  varied  from  32  to  9  per  cent,  and  the 
infantile  from  50  to  85  per  cent.  The  modern  method  of  treat- 
ment has  given  a  maternal  mortality,  in  the  hands  of  various 
observers,  of  from  1  to  4  per  cent.,  whilst  even  the  infantile 
mortality  has  been  lowered.  The  facts,  then,  at  our  disposal 
prove  clearly  that  by  any  and  all  methods  the  child  suffers 
excessively,  whilst  for  the  woman  there  is  a  choice  in  method. 

The  question  may  be  summed  up  as  follows  :  The  risk  to 
the  woman  increases  progressively  to  term  after  the  first  hsemor- 
rhage.  On  the  occurrence  of  this  haemorrhage  the  child  is 
viable.  Renewed  haemorrhage  simply  risks  viability.  The 
interests  of  the  child,  therefore,  are  not  subserved  by  expect- 
ancy. Those  of  the  woman  are  actually  imperiled.  The 
teaching  is  sound,  therefore,  which  says  :  On  the  occurrence  of 
the  first  haemorrhage,  whether  profuse  or  not,  elect  the  induc- 
tion of  premature  labor.  The  earlier  the  haemorrhage,  the 
greater  the  chance  of  the  placenta  being  implanted  centrally. 
It  is  central  implantation  which  at  term  subjects  the  woman  to 
the  greatest  risks  and  holds  out  but  very  slim  chance  for  the 
child. 

3.  Eclampsia  as  an  Indication  for  the  Induction  of  Prema- 
ture Labor. — Absolute  statement  in  regard  to  this  indication  is 
not  wise  owing  to  the  very  just  diversity  of  opinion  amongst 
experienced  obstetricians.  To  reach  an  approximately  accu- 
rate conclusion  it  will  be  necessary  to  sharply  differentiate  the 
instances  where  eclampsia  seems  imminent  and  those  where 
convulsions  have  developed. 

Albuminuria  is  an  almost  constant  forerunner  and  accom- 
paniment of  eclampsia.  Such,  at  least,  is  the  rule  with  but  rare 
exceptions.  The  albuminuria  may  or  may  not  be  dependent  on 
organic  renal  disease,  and  in  the  latter  instance  it  may  or  may 
not  lead  to  organic  disease.     The  question,  therefore,  which  the 


INDUCTION  OF  PREMATURE  LABOR.  55 

physician  has  chiefly  to  face  is  the  immediate  risk  to  mother  and 
child  if  pregnancy  be  allowed  to  progress  to  term,  remembering 
that  in- no  given  case  can  it  be  predicated  that  the  emptying  of 
the  uterus  will  ward  off  the  convulsions,  and  also  that  the  inter- 
ference with  gestation  may  excite  convulsions.  The  problem, 
it  is  evident,  is  most  complex.  Still,  the  following  considera- 
tions help  toward  its  solution. 

In  the  vast  majority  of  instances,  the  development  of 
eclampsia  leads  to  premature  labor.  If  we  do  not  shut  our  eyes, 
then,  to  nature's  teachings,  it  seems  wise,  in  the  presence  of 
eclampsia,  to  resort  to  such  measures  as  will  hasten  the  empty- 
ing of  the  uterus  instead  of  to  such  as  will  tend  to  protract  the 
gestation.  The  latter  course,  certainly,  will  avail  naught  to  the 
child,  for  its  life  is  directly  imperiled  by  the  first  eclampsic 
attack,  and,  should  it  survive  this  and  labor  not  occur  spontane- 
ously, its  chances  of  living  through  further  attacks  are  all  the 
less.  As  regards  the  woman,  if  spontaneous  premature  labor 
do  not  occur  during  the  first  attack,  experience  teaches  that  the 
liability  to  further  attacks  is  greater  if  the  uterus  has  not  been 
emptied  tlian  where  it  has.  The  first  attack  exhausts  the 
woman,  if  it  do  no  more.  The  second  attack  adds  to  her  ex- 
haustion and  may  kill.  Therefore,  in  the  presence  of  eclampsia 
it  may  be  stated  that,  in  general,  nothing  is  gained  by  endeav- 
oring to  protract  gestation  and  everything  may  be  lost.  One  of 
the  recognized  methods  of  treatment  of  eclampsia  is  deep  anses- 
thesia  protracted,  if  need  be,  for  hours.  During  this  anaesthesia 
resort  to  the  measures  we  shall  shortly  consider  will  empty  the 
uterus  possibly  of  a  live  child,  for  at  the  period  of  gestation 
under  consideration  the  child  is  viable ;  otherwise  it  becomes  a 
question  of  artificial  abortion, — a  subject  already  considered. 

Where  convulsions  are  imminent,  there  is  even  greater 
diversity  of  opinion  as  to  the  advisability  of  inducing  labor. 
Whilst  apparently  imminent,  they  may  never  occur;  the  induc- 
tion of  premature  labor  may  not  ward  them  off;  indeed,  the 
measures  necessary  for  induction  may  provoke  convulsions.     In 


56  OBSTETRIC     SURGERY. 

the  face  of  this  fair  statement  of  fact,  what  ground  is  there  for 
advocating-  the  operation  1 

Supposing  that,  in  spite  of  resort  to  the  recognized  methods 
of  treatment  of  albuminuria,  in  particular  absolute  milk  diet 
combined  with  iron,  the  albumin  increases  in  amount,  headache 
and  visual  disturbances  appear,  dropsy  to  a  greater  or  less  de- 
gree sets  in.  The  woman  has  reached  the  seventh  month  ;  the 
child  is  viable,  and  the  foetal  heart  certifies  that  it  is  alive.  It 
may  be  safely  predicated  that  the  chances  are  that  this  woman 
will  have  eclampsia  before  or  at  term,  during  labor  or  afterward. 
If  she  do  before  the  onset  or  the  completion  of  labor,  the  child's 
chances  of  survival  are  very  slight.  Meantime  the  woman  risks 
aggravation  in  the  renal  symptoms  and  condition,  disturbances 
of  vision  more  or  less  permanent,  puerperal  mania,  and  puer- 
peral paralysis.  Now,  if  the  operation  of  inducing  premature 
labor  be  elected  at  the  period  under  consideration,  the  child's 
chances  are  better  even  if,  as  tlie  result  of  tlie  manipulations, 
eclampsia  is  induced ;  for,  as  already  stated,  in  the  presence  of 
eclampsia  rapid  emptying  of  the  uterus  is  advisable.  As  for  the 
woman,  medical  and  dietetic  treatment  having  failed  to  arrest 
the  progress  of  albuminuria  (the  usual  forerunner  of  eclampsia), 
the  induction  of  premature  labor  may  save  her  the  complications 
just  enumerated,  to  any  and  all  of  which  she  is  liable  if  the 
pregnancy  is  allowed  to  go  to  terra.  Should  eclampsia  develop 
as  the  result  of  the  necessary  manipulations,  labor  having  been 
started  it  may  be  more  quickly  ended  than  if  emptying  of  the 
uterus  is  forced  upon  the  physician  by  the  spontaneous  occur- 
rence of  convulsions. 

As  the  case  has  been  stated,  therefore,  the  immediate  and 
the  remote  welfare  of  the  woman  calls  for  the  induction  of 
premature  labor  in  instances  where  the  development  of  eclamp- 
sia is  feared;  and  this  fact  should  outweigh  the  argument,  from 
the  side  of  the  child,  that  its  chances  of  survival  are  less  the 
earlier  before  term  it  is  born,  whether  spontaneously  or  arti- 
ficially.    To  be  born  in  the  midst  or  at  the  expiration  of  an 


INDUCTION    OF    PREMATURE    LABOR.  57 

eclampsic  seizure  at  the  eighth  month  or  at  term  imperils  its 
existence  fully  as  much  as,  with  our  modern  methods  of  rearino- 
premature  infants,  its  chances  of  survival  are  relatively  great. 

Modern  opinion  is  tending  toward  the  acceptance  of  this 
view.  liusk  protests  against  postponing  resort  to  the  induction 
of  premature  labor  until  the  grave  symptoms  (chiefly  cerebral) 
which  precede  eclampsia  develop.  Tarnier,  of  the  French 
school,  holds  practically  the  same  opinion.  The  opponents  of 
this  view  are  certainly  many,  and  their  names  carry  weight;  but 
a  careful  estimate  of  the  question,  both  from  the  stand-point  of 
the  woman  and  of  the  child,  forces  on  us  the  conclusion  that, 
dietetic  and  medicinal  measures  having  failed  to  ameliorate  the 
symptoms  which  precede  eclampsia,  the  best  interests  of  both  are 
subserved  by  the  election  of  premature  labor. 

Such,  briefly  outlined,  are  the  indications  for  the  induction 
of  premature  labor.  In  determining  the  best  method  for  per- 
forming the  operation,  the  fact  must  never  be  lost  sight  of  that 
the  intent  of  the  operation  will  ordinarily  be  to  save  the  woman 
the  greater  risk  she  suffers  if  allowed  to  go  to  term,  and  also  to 
obtain  a  living  child.  To  amply  satisfy  this  intent  in  the  indi- 
vidual case,  the  operation,  where  election  is  possible,  should  be 
postponed  to  as  near  term  as  is  absolutely  consistent  with  the 
interest  of  the  mother,  for  thus  the  chances  of  the  infant's  life 
are  increased.  Further,  the  method  selected  should  be  one 
which,  while  the  safest  for  the  woman,  takes  into  full  account 
the  phenomena  of  normal  labor,  since  thus  alone  are  the  inter- 
ests of  the  child  fully  subserved.  Again,  in  view  of  the  fact 
that  the  child  has  not  attained  full  maturity,  ample  preparation 
should  be  made  beforehand  for  the  rearing  of  the  immature 
child.  Finally,  the  physician  should  be  prepared  to  meet  every 
emergency  which  labor  at  term  miglit  involve;  for  premature 
labor  may  call,  before  it  is  completed,  for  any  of  the  obstetric 
operations  (the  forceps,  version),  and  its  completion  may  be 
followed  by  the  same  complications  as  labor  at  term  (h£emor- 
rhage,  adherent  placenta). 


58  OBSTETRIC  SURGERY. 

METHODS  FOR  THE  INDUCTION  OF  PREMATURE  LABOR. 

Many  of  the  methods  which  have  been  proposed  for  the 
induction  of  premature  labor  are  purely  of  interest  from  an  his- 
torical stand-point.  Such,  for  instance,  is  the  administration  of 
medicinal  agents, — ergot,  rue,  quinine,  cinnamon,  and  the  like. 
These  drugs  will  not  provoke  contractions,  although  some 
of  them  will  intensify  action  when  contractions  are  in  force. 
Again,  it  has  been  suggested  to  start  the  expulsive  action  of 
the  uterus  by  injecting  water  or  air  between  the  membranes  and 
the  uterine  wall.  Such  a  procedure  would  doubtless  be  effect- 
ive, but  should  not  be  countenanced,  since  it  is  likely  to  rupture 
the  membranes,  thus  imperiling  the  child,  and  since  it  may 
prove  fatal  to  the  woman  from  the  entrance  of  air  into  the 
uterine  veins.  Vaginal  irrigation  with  hot  water  is  slow  and 
uncertain  in  action,  and,  if  prolonged,  may  give  rise  to  local 
conwstion.  unfavorable  alike  to  woman  and  foetus.  As  will  be 
noted,  this  method,  within  limits,  is  useful  as  preparatory  to 
other  methods,  in  that  by  means  of  it  softening  of  the  cervix 
mav  be  assisted.  Electricity  is  of  value  only  as  an  adjuvant  for 
hastening  labor  through  re-enforcing  contractions  when  tliese 
have  once  been  started.  Used  alone,  this  agent  is  very  prob- 
lematical in  effect,  and  highly  uncertain  as  well. 

There  are  left  for  consideration  the  following  five  methods: 
1.  Puncture  of  the  membranes.  2  Tamponing  the  vagina. 
3.  The  injection  of  glycerin.  4.  The  insertion  of  an  elastic 
bougie  between  the  membranes  and  the  uterine  wall.  5. 
Mechanical  dilatation  of  the  cervix. 

1.  Puncture  of  the  Memhrnnes. — This  may  be  accomplished 
in  two  ways, — by  direct  puncture  through  the  cervical  canal ; 
by  insinuating  a  uterine  sound  on  a  sharpened  goose-quill 
between  the  uterine  wall  and  the  membranes  and  tapping  the 
membranes  high  up  by  projecting  the  quill  over  the  stylet. 
This  method  was  formerly  highly  in  favor  with  the  Vienna 
school. 


INDUCTION    OF   PREMATURE    LABOR.  59 

Puncture  of  the  membranes  Avill  certainly  induce  labor, 
and,  where  aseptically  performed,  the  method  may  be  ranked 
as  safe  for  the  woman.  The  method,  however,  is  open  to  the 
objection  that  it  does  not  imitate  natural  methods,  and  there- 
fore may  imperil  the  child.  In  the  course  of  normal  labor 
premature  rupture  of  the  membranes  invariably  leads  to  tedious 
labor,  and  this  may  entail  both  maternal  and  foetal  exhaustion. 
Our  aim  should  be  to  maintain  the  dilating  water-wedge  intact. 
This  is  the  sound  rule  of  practice  in  the  course  of  spontaneous 
labor  at  term.  Similarly,  in  case  of  the  induction  of  premature 
labor,  an  operation  resorted  to  in  the  interests  of  the  child  as 
well  as  in  those  of  the  woman,  tlie  object  should  be  to  maintain 
the  membranes  intact,  in  order  to  avoid  a  protracted  first  stage 
of  labor,  with  its  concomitant  risks.  Therefore,  puncture  of 
the  membranes  should  be  dismissed  from  consideration  as  a 
means  of  inducing  premature  labor. 

2.  Tamponing  the  Vagina. — Thorough  tamponing  of  the 
vagina  by  means  of  aseptic  tampons  will  unquestionably,  in 
course  of  time,  provoke  uterine  contractions,  and  the  more 
speedily  the  nearer  the  woman  is  to  term.  The  method,  if 
aseptic  throughout,  carries  with  it  no  risk  either  to  the  woman 
or  the  child,  but  it  is  slow  in  action.  Days  may  elapse  before 
effects  on  the  uterus  are  noted.  Now,  when  speaking  of  the 
indications  under  which  the  induction  of  premature  labor  was 
justifiable,  we  have  noted  tliat  in  pelvic  contraction,  for  in- 
stance, it  was  highly  important  not  to  err  in  the  date  assigned 
for  the  operation,  and  that  under  the  best  possible  conditions 
there  existed  a  chance  of  error  of  at  least  a  fortnight.  Obvi- 
ously, no  method  should  be  selected  for  the  induction  of  prema- 
ture labor  which  carries  with  it  the  strong  probability  of  greatly 
magnifying  this  chance  of  error.  The  selection  of  such  a 
method  is  not  fair  to  the  child.  Neither  under  other  indications 
is  it  fair  to  the  woman.  If  eclampsia  threaten,  for  instance, 
and  the  physician  determines  that  labor  should  be  induced,  he 
cannot  afford  to  place  dependence  on  a  method  which  may  not 


60  OBSTETRIC     SURGERY. 

prove  eft'ective  for  days.  There  exists,  indeed,  but  one  indica- 
tion under  which  the  tampon  might  fill  a  place,  and  this  is  in 
the  event  of  premature  labor  being  indicated  by  haemorrhage, 
due,  likely  enough,  to  faulty  placental  insertion.  Here  the 
tampon  prevents  further  hsemorrhage  whilst  the  cervix  is  di- 
lating sufficiently  to  warrant  resort  to  the  next  step  in  treat- 
ment. The  colpeurynter  of  the  late  Karl  Braun  is  an  excellent 
agent  for  tamponing  the  vagina  in  such  an  instance,  but  it  can 
never  fill  the  place  of  the  aseptic  gauze,  in  private  practice  cer- 
tainly, for  the  reason  that  it  is  made  of  rubber, — an  agent  which 
deteriorates  with  certainty  in  course  of  time,  and  can  therefore 
not  be  depended  upon  as  to  quality.  Further,  it  is  not  as 
strictly  aseptic  as  sterilized  gauze. 

When  the  tampon  is  indicated  it  should  be  inserted  under 
the  strictest  asepsis,  and  with  the  patient  in  the  knee-chest  or  in 
the  left  lateral  position,  for  thus  alone  can  the  vaginal  fornices 
be  efficiently  packed.  An  iodoform  or  borated  gauze  inserted 
in  a  continuous  strip  forms  the  best  tampon.  If  uterine  con- 
tractions be  not  established  within  thirty  hours  the  strip  should 
be  removed,  the  vagina  douched  wdth  2-per-cent.  creolin  solution 
or  with  1  to  8000  solution  of  bicliloride,  and  a  new  strip  in- 
serted, unless  the  cervix  is  found  sufficiently  dilated  for  resort 
to  methods  the  aim  of  which  is  to  empty  the  uterus  rapidly. 

3.  Injections  of  Glycerin  for  tJie  Induction  of  Premature 
Labor. — This  method  has  recently  been  highly  commended  in 
Germany,  and  on  the  few  occasions  when  it  has  been  tested  in 
this  country  the  success  has  been  fairly  uniform.  The  cases  on 
record  are  too  few  to  admit  of  positive  statement.  In  our  own 
hands  success  has  not  been  marked,  but  when  we  tested  it  the 
technique  had  not  been  perfected  as  it  has -at  the  present. 
Glycerin,  when  injected  into  the  uterus  between  the  membranes 
and  the  uterine  wall,  acts  by  causing  exosmosis  from  the  amni- 
otic sac.  There  is  a  profuse  secretion  of  "fluid  fi'om  the  uterus, 
and  concomitantly  uterine  contractions  set  in.  The  method  of 
procedure  is  the  following  : — 


INDUCTION  OF  PREMATURE  LABOR.  61 

The  external  genitals  and  the  vagina  having  been  rendered 
thoroughly  aseptic,  a  sterilized  gum-elastic  catheter  is  insinuated 
to  the  fundus,  between  the  membranes  and  the  uterine  wall. 
The  woman  is  then  placed  in  the  knee-chest  or  in  the  left  lateral 
position ;  the  catheter  is  connected  by  means  of  a  sterilized  rub- 
ber tube  with  a  glass  funnel,  and  into  the  funnel  is  poured 
sterilized  glycerin.  Under  the  influence  of  gravity  this  flows 
into  the  uterus.  The  catheter  is  carefully  withdrawn,  and  the 
vagina  is  tamponed  with  sterilized  gauze.  The  woman  should 
maintain  the  lateral  position  for  a  number  of  hours,  otherwise 
the  glycerin  will  flow  from  the  uterus  and  the  effects  of  the  in- 
jection will  be  nullified.  Uterine  contractions  should  be  evolved 
in  the  course  of  a  few  hours,  otherwise  the  procedure  will  have 
to  be  repeated.  Instead  of  the  glass  funnel  a  syringe  may  be 
used  for  injecting  the  glycerin.  It  goes  without  saying  that 
every  precaution  should  be  taken  against  the  injection  of  air 
into  the  uterus.  The  objections  to  this  method  which  suggest 
themselves  at  the  present  are  that  it  is  uncertain  in  its  action, 
and  therefore,  where  the  indication  calling  for  the  induc- 
tion of  premature  labor  is  an  urgent  one,  the  physician  is 
scarcely  justified  in  taking  the  chances  of  failure.  A  further 
objection  is  the  risk  of  rupturing  the  membranes  during  the  in- 
troduction of  the  catheter, — an  accident  which,  should  it  occur, 
places  the  welfare  of  the  child  in  an  unfavorable  light.  Further, 
recent  data  would  seem  to  prove  that  nephritis  may  result. 
The  future,  however,  may  speak  with  more  favor  for  this 
method  than,  at  the  present,  we  are  inclined  to  grant  it. 

4.  The  Insertion  of  an  Elastic  Bougie  between  the  Mem- 
hranes  and  the  Uterine  Wall  {Krause's  Method). — The  method 
of  inducing  labor  by  the  introduction  of  an  elastic  bougie  be- 
tween the  membranes  and  the  uterine  wall  is  probably  resorted 
to  with  greater  frequency  than  any  other.  The  bougie  acts  as 
a  foreign  body,  and  at  a  variable  interval  provokes  uterine  action 
with  certainty.  The  method  is  safe  for  the  woman,  provided 
proper  asepsis  accompany  the  insertion  of  the  instrument.    There 


62  OBSTETRIC     SURGERY. 

are  weighty  objections  against  it,  however.  In  the  first  place 
the  presence  of  the  bougie  in  the  uterus  may  not  induce  labor 
for  some  days,  and  exceptionally  not  at  all,  unless  it  be  rotated 
in  the  uterus  with  the  aim  of  separating  to  a  degree  the  attach- 
ment of  the  membranes.  When  the  induction  of  premature 
labor  has  been  duly  elected  by  the  physician,  nothing  is  gained 
by  awaiting  what  in  any  case  may  prove  the  slow  action  of  the 
bougie;  and,  for  reasons  already  amply  considered,  delay  may 
mean  the  loss  of  the  child.  Further,  in  introducing  the  bougie 
(a  step  not  always  easy  of  performance)  the  membranes  may  be 
ruptured,  and  this  accident  it  is  very  desirable  to  avoid  in  the 
interest  chiefly  of  the  child  and  partly  also  of  the  woman.  Ro- 
tation of  the  bougie  within  the  uterus  is  objectionable:  first, 
on  account  of  the  possibility  of  injuring  the  placenta,  with 
resulting  hsemorrhage  (perhaps  of  the  concealed  type, — so  fatal 
both  to  the  woman  and  to  the  child),  and,  secondly,  on  account 
of  the  risk,  again,  of  rupture  of  the  membranes.  Lastly,  it  is 
not  a  very  easy  matter  to  asepticize  the  bougie.  Soaking  in 
weak  antiseptic  solutions  will  not  suffice,  and  soaking  in  strong- 
will  injure  the  bougie.  The  material  of  which  the  bougie  is 
constructed  forbids  its  subjection  to  the  most  reliable  method  of 
obtaining  asepsis, — exposure  to  dry  heat.  It  is  evident,  there- 
fore, that  this  method  is  not  an  ideal  one ;  still,  it  is  the  best  at 
our  disposal,  and,  where  the  emergency  calling  for  the  induction 
of  premature  labor  was  not  a  very  urgent  one,  this  method 
has  answered  well.  In  case  of  urgency,  however,  it  must  be 
supplemented  by  a  further  step,  wliicli  we  will  shortly  describe. 
Technique  of  Krause''s  Metliod. — The  instruments  requisite 
are  a  speculum  (preferably  the  Sims),  a  steel-branched  dila- 
tor, and  a  tenaculum.  The  external  genitals  and  the  vagina 
having  been  tlioroughly  asepticized,  the  woman  is  placed  in 
the  left  lateral  position,  and  the  cervix  is  exposed  through 
the  speculum.  The  tenaculum  is  inserted  into  the  anterior 
lip  of  the  cervix  to  steady  the  uterus,  and  the  cervical  canal 
is  dilated  to   the  extent  of  a  half-mch  by  the  steel-branched 


INDUCTION    OF   PREMATURE    LABOR.  63 

dilator.  This  step  is  requisite  in  order  to  enable  the  passage 
of  the  bougie  with  least  risk  of  injuring  the  integrity  of 
the  membranes.  The  asepticized  bougie  is  then  carefully  in- 
sinuated to  the  fundus,  between  the  membranes  and  the  uterine 
wall.  A  tampon  of  sterilized  gauze  is  inserted  into  the  vagina 
to  keep  the  bougie  from  slipping  from  the  uterus.  The  woman 
is  put  to  bed  and  remains  there  until  uterine  contractions  are 
evoked.  In  the  event  of  these  contractions  not  supervening 
within  twenty-lour  hours,  the  bougie  must  be  removed,  the 
vagina  douched  with  creolin  solution,  and,  if  the  emergency  is 
still  not  pressing,  a  second  sterilized  bougie  is  inserted.  If 
uterine  contractions  have  been  evoked,  then,  if  the  emergency 
be  not  pressing,  the  progress  of  labor  is  left  to  nature.  In  the 
event  of  a  complication  arising  calling  for  speedy  delivery,  the 
pliysician  may  resort  to  the  method  shortly  to  be  described. 

5.  Dilatation  of  the  Cervix  as  a  Means  of  Inducing  Pre- 
mature Labor. — With  this  method  as  a  working  basis,  labor 
may  be  induced  and  completed  within  fairly  normal  limits,  with 
less  risk  to  the  woman  and  the  child  than  by  any  other  method. 
Under  this  heading,  then,  the  operation  for  the  induction  of 
premature  labor  will  be  described. 

The  operation  having  been  elected,  ever — except  in  strict 
emergency — under  the  support  of  a  consultant,  the  physician 
will  ordinarily  have  ample  time  to  thoroughly  cleanse  the  intes- 
tinal canal  by  the  administration  of  one  or  another  laxative,  or, 
failing  sufficient  time  for  this,  the  lower  bowel,  at  any  rate, 
should  be  emptied  by  a  copious  enema.  Convalescence  from 
any  obstetrical  operation  is  favored  Avhen  the  great  emunctory 
of  the  system  is  neither  clogged  nor  torpid.  The  bladder  is 
emptied  and  the  field  of  operation  is  carefully  asepticized  as  fol- 
lows :  The  labia  and  vestibule  are  thoroughly  washed  with  soap 
and  water,  and  then  with  a  2-per-cent.  creolin  or  with  a  1  to 
5000  sublimate  solution.  By  means  of  a  small  tooth-brush  the 
vagina  is  similarly  prepared.  Simple  douching  of  the  vagina  is 
not  sufficient,  since  the  folds  of  the  canal  cannot  thus  be  ren- 


64  OBSTETRIC     SURGERY. 

dered  aseptic.     The  physician,  and  whoe^  er  assists  him.  should 

scrub  his  hands  with  soap  and  water,  and  next  immerse  them 
in  a  2-per-cent.  cr-^'^lin  or  n.i  a  i  to  "2000  sublimate  solutiou. 

The  instruix. ■"..:-  nLLOSsary  are  the  Ibllowing :  A  Sims 
speculum,  an  intra-uterine  forceps,  a  tenaculum,  a  steel-branched 
dilator.  These  are  to  be  carefully  disinfected  beforehand,  and 
at  the  time  or  use  mar  he  nlaced  in  sterilized  water  or  in  an 
antiseptic  solutiun,  accoiuini,  tL>  :ne  preference  of  the  individual 
operator.  About  two  yards  of  sterilized  gauze,  two  inches  in 
width,  are  also  needed. 

Such  ar^"^  ^b^-  precautions  which  are  strictly  essential  in 
order  to  2'na:  '.  :b-  ^^'oinan  a^'ainst  her  main  risk, — septic  infec- 
tion. Tbc  b.  1  ^ /.  1  b  vinu  oeeu  em] itied,  the  woman  is  placed 
in  the  loi:  '._.:■. rul  nc>-ibon,  the  speculum  inserted,  and  the  ten- 
aculum fixed  in  the  anterior  cerAical  lip.  In  rare  instances  it 
may  be  necessary  to  dilate  the  cervical  canal  to  the  extent  of 
half  an  inch  before  proceeding  to  the  next  step  ;  this,  however, 
will  prove  the  exception  beyond  the  seven  and  one-halt  months 
of  gestation,  owing  to  the  softened  condition  of  the  cerAucal 
tissues  at  this  period.  The  steriUzed  gauze  is  grasped  by  the 
packing  forceps  and  carried  into  ^he  cervix  up  to  and  not  beyond 
the  internal  os.  The  cervical  ^ :;.  J  is  thus  progressively  packed 
full,  and  the  remainder  of  tb'::-  2'auze  is  utilized  to  tampon  the 
upper  vagina.  The  object  of  the  gauze  is  twofold;  it  will  in 
all  probability  excite  utoriiie  contractions,  but.  if  it  do  not,  it 
mechanically  lanates  tne  c^r^vix  to  a  sufficient  degree  to  enable 
the  next  step  to  be  resorted  to.  The  patient  is  placed  in  bed, 
and,  in  tb^r  evc-nt  of  the  presence  of  the  gauze  being  painful,  a 
suppository  '^-f  two  o-yai-v  of  cod^rine  may  be  inserted  into  the 
rectum,  AVibnin  tcv.  to  twenty-i-'ir  I'^urs  the  gauze  will  prob- 
ably excite  contractions,  with  tb^  -i^-at^-r  certainty  the  nearer 
tb-  w-jinan  is  to  term.  The  pby-ician's  duty  now  becomes  ex- 
n  :^  r.t  '-':■  artive.  according  to  the  emei^encv  wliich  has  de- 
munb'-..  t:ie  induction  of  premature  labor.  In  the  event  of  the 
in^brcation  for  rapidly  terminating  labor  not  being  urgent,  the 


INDUCTION    OF    PREMATURE    LABOR.  65 

gauze  is  removed,  under  aseptic  precautions,  and  the  labor 
may  be  allowed  to  progress  toward  its  natural  termination.  The 
physician's  duty  is  purely  passive,  even  as  it  is  during  the  prog- 
ress of  normal  labor.  This  applies  particularly  to  instances 
where  labor  is  induced  in  the  presence  of  a  contracted  pelvis, 
where  the  lapse  of  even  twenty-four  hours  has  no  untoward 
effect  on  either  tlie  woman  or  the  child.  Here,  until  full  dila- 
tation of  the  cervix,  artificial  aid  is  only  called  for  under 
stringent  indication  from  the  side  of  the  woman  or  the  child, 
such  as  hsemorrhage  or  evidence  of  fcetal  heart-failure.  It  is 
absolutely  essential  to  maintain  the  integrity  of  the  membranes, 
since,  the  cervix  once  dilated,  the  safety  of  the  woman  or  of 
the  child,  or  the  degree  of  pelvic  contraction  may  call  for  the 
deliberate  election  of  version. 

In  the  event  of  contractions  not  having  been  induced,  if 
no  emergency  requiring  specially  active  measures  be  present, 
the  physician,  under  strict  asepsis,  may  insert  another  strip  of 
gauze ;  but  if  the  indications  be  pressing,  the  cervical  tissues 
have  been  dilated  to  a  degree  by  the  gauze,  and  have  been 
softened  so  that  it  is  possible  to  resort  to  the  next  step  in  the 
operation,  which,  in  the  vast  majority  of  cases,  will  give  the 
physician  full  control  of  the  case. 

The  aim  of  the  step  to  which  we  now  pass  is  to  secure  full 
dilatation  of  the  cervix  or,  in  any  event,  sufficient  dilatation  to 
enable  the  physician  to  resort  to  version,  the  conditions  under 
the  premises  being  still  favorable  for  this  operation.  According 
to  whether  the  indication  for  interference  be  urgent  or  not,  the 
physician  may  elect  one  of  two  procedures, — the  first,  in  case 
delay  of  a  few  hours  seems  allowable ;  the  second,  if  delivery 
is  necessary  within  as  brief  a  space  of  time  as  is  consistent  with 
inflicting  no  damage  on  the  cervix  and  lower  uterine  segment. 
Both  measures  entail  mechanical  dilatation  of  the  cervix. 

The  first  method  consists  in  the  use  of  Barnes's  hydrostatic 
bags  or  their  essential  modification,  McLean's  bags ;  the  second 
depends  on  the  use  of  the  hand,  a  method  not  highly  favored 


66 


OBSTETRIC     SURGERY. 


because  of  the  objectionable  and  erroneous  term  applied  to  it, — 
accouchement  force. 

The  difference  between  Barnes's  and  McLean's  bags  is  that 
the  former  has  but  one  compartment,  removal  being  necessitated 
for  the  insertion  of  progressively  larger  sizes.  McLean's  bag, 
on  the  other  hand,  has  two  compartments,  so  that  when  the 
cervical  canal  has  been  dilated  to   the  full  extent  of  one  com- 


Fig.  28.— Barnes's 


Fig.  29.— McLean's  Bag. 


partment  the  other  may  be  brought  into  action  without  removal 
of  the  bag. 

The  method  of  usins:  these  hvdrostatic  dilators  is  the  fol- 
lowing:  The  vagina  and  the  external  genitals  having  been 
asepticized,  and  the  bag  and  the  forceps  having  been  similarly 
treated,  the  bag  is  seized  in  the  grasp  of  the  forceps,  and,  under 
the  guidance  of  one  or  two  fingers  in  the  vagina,  it  is  inserted 
into  the  cervical  canal  just  beyond  the  internal  os.  If  uterine 
contractions   are   present   the    attempt    at   insertion   should   be- 


INDUCTION  OF  PREMATURE  LABOR.  67 

made  in  the  interval  of  the  contractions,  in  order  to  avoid  pos- 
sible rupture  of  the  membranes.  The  bag-  being  in  place,  the 
forceps  is  withdrawn,  the  rubber  tube  of  the  bag  is  connected 
with  a  Davidson  syringe,  and  the  bag  is  distended  with  sterilized 
water.  The  object  in  using  sterilized  water  is  to  avoid  septi- 
cizing  the  uterus,  in  case  the  bag  should  rupture.  The  rubber 
tube  is  then  clamped  and  the  patient  is  put  to  bed.  Ordinarily, 
after  the  lapse  of  two  hours,  the  cervical  canal  has  been  dilated 
to  the  full  extent  of  the  single  compartment  of  the  McLean 
bag^  and  the  tube  of  the  second  compartment  is  connected  with 
the  syringe  and  similarly  distended  with  sterilized  water.  In 
about  an  hour  more  the  cervix  has  been  sufficiently  dilated  to 
enable  the  physician  to  resort  to  delivery  of  the  foetus,  prefer- 
ably by  version,  if  the  integrity  of  the  membranes  has  been 
maintained. 

It  is  at  once  obvious  that  this  method  will  not  answer 
where  the  emergency  requiring  interference  is  urgent,  as,  for 
instance,  in  case  of  placenta  prsevia  or  eclampsia.  Here  time 
is  an  important  factor,  and  a  more  rapid  method  is  called  for. 
Of  late  years  a  method  of  rapid  dilatation,  called  by  the  French 
the  accouchement  force^  has  been  resuscitated  from  unmerited 
oblivion,  and  in  the  presence  of  the  emergencies  just  noted  it 
offers  the  best  aid  to  the  woman,  and  also  about  the  only  hope 
for  the  child.  The  reason  why  the  method  fell  into  disuse  and 
has  been  reprobated  by  obstetricians  generally  up  to  a  compara- 
tively recent  date  is  because  of  the  name  which  was  applied  to 
it.  The  fact  is  that  absolutely  no  force  need  be  used  or  is  used 
in  securing  dilatation.  The  method  depends  for  its  success  on 
the  well-recognized  fact  that  any  muscle  in  the  body  will  yield 
to  continuously  applied  pressure.  The  procedure  is,  of  course, 
tiresome  to  the  operator,  but  the  clinical  results  which  may  be 
secured  through  timely  resort  to  it  will  amply  compensate.  The 
technique  is  the  following :  The  woman  being  deeply  anees- 
thetized,  and  the  genital  tract  having  been  thoroughly  asep- 
ticized, the  hand  is  introduced  into  the  vagina  and  the  index 


68  OBSTETRIC     SURGERY. 

finger  is  inserted  into  the  cervical  canal.  Steady  pressure  is 
maintained,  and  shortly  it  will  be  found  possible  to  insert  the 
middle  finger.  Progressively  thus  finger  after  finger  is  inserted, 
until  the  entire  hand  has  been  introduced.  The  fist  is  then 
doubled  and  in  a  few  minutes  the  remaining  obstacle  to  dilata- 
tion will  be  found  to  yield  and  the  physician  can  at  once  take 
the  subsequent  steps  requisite  for  delivery. 

We  would  again  impress  the  fact  that  this  method  should 
be  reserved  for  strict  emergency.  The  risk  the  method  subjects 
the  woman  to  is  laceration  of  the  cervix,  the  rent  from  which 
mi"ht  even  extend  into  the  lower  uterine  segment.  This 
major  accident  should  not,  however,  occur  unless  the  cardinal 
rule  is  neglected,  which  is  to  use  absolutely  no  force,  but  to 
cause  the  cervix  to  yield  to  the  applied  pressure.  In  the  event 
of  a  minor  laceration  of  the  cervix  occurring,  the  immediate 
operation  on  the  cervix  should  be  performed.  This  will  be 
described  in  its  proper  place. 

Both  these  methods — the  use  of  the  hydrostatic  dilators  as 
well  as  manual  dilatation — evoke  uterine  contractions  as  well  as 
dilate  the  cervical  canal.  These  methods  constitute  at  the  pres- 
ent the  ideal  ones  of  inducing  labor.  They  fulfill  every  requisite 
indication.  They  are  aseptic.  They  start  labor  by  the  natural 
method,  by  evoking  uterine  contractions  without  the  possible 
sacrifice  of  the  child  through  premature  rupture  of  the  mem- 
branes ;  as  a  rule,  they  enable  delivery  to  be  effected  within 
fairly  normal  limits.  They  necessitate,  of  course,  the  constant 
attention  of  the  physician  after  the  completion  of  the  first  step, 
the  provoking  of  uterine  contractions,  but,  as  noted  under  indi- 
cations, such  attendance  is  requisite  in  order  to  fulfill  strictly  the 
aim  of  the  operation,  which  is  the  safety  both  of  the  woman  and 
the  child.  At  any  time  it  may  become  necessary  to  interfere 
actively  in  the  interests  of  either.  The  first  stage  once  com- 
pleted, labor  is  ended  spontaneously  or  by  forceps  or  version, 
according  to  the  individual  case. 

Prognosis. — The  prognosis  of  the  operation  for  the  indue- 


INDUCTION    OF    PREMATURE    LABOR.  69 

tion  of  premature  labor  obidously  will  vary  according  to  the 
indication  which  requires  it.  If  resorted  to  in  the  presence  of 
eclampsia  or  placenta  prsevia,  the  result  both  for  woman  and 
child  is  necessarily  more  unfavorable  than  when,  the  emergency 
not  being  an  extreme  one,  the  physician  has  time  at  his  disposal 
for  the  due  election  of  each  and  every  step.  Everything, 
further,  it  should  be  re-iterated,  depends  on  the  careful  observ- 
ance of  strict  asepsis.  Whilst  the  prognosis  should  be  guarded, 
in  general  it  may  be  stated  that  the  operation  should  not  have 
a  mortality  rate.  Election  of  the  operation  and  asepsis  are  the 
key-notes  of  success. 

As  regards  the  child,  its  chances  of  survival  are  the  less  the 
earlier  the  stage  of  gestation  at  which  the  operation  is  resorted 
to.  Under  the  tliirty-sixth  week  the  infant  can  only  be  reared 
through  the  exercise  of  every  possible  care.  In  hospital  prac- 
tice, with  modern  appliances,  it  ought  to  be  possible  to  save,  at 
the  thirty-sixth  week  (the  ninth  lunar  month),  fully  85  per  cent, 
of  the  children.  This  has  been  accomplished  by  means  of  the 
incubator  and  forced  feeding.  At  the  Paris  Maternity,  30  per 
cent,  of  children  at  the  sixth  month  have  been  thus  reared, 
63.6  per  cent,  at  seven  months,  and  85.7  per  cent,  at  eight 
months.  These  figures  refer  to  calendar  months.  In  private 
practice,  and  particularly  in  country  districts,  it  is  not  possible 
to  always  obtain  an  incubator,  and  the  physician  must  do  the 
best  possible  by  means  of  an  improvised  incubator,  such  as  an 
oven,  the  temperature  being  maintained  at  about  90°  F.  Re- 
cently, an  inexpensive  and  portable  incubator,  so  simple  in 
construction  that  trained  intellect  is  not  necessary  for  its  man- 
agement, has  been  devised  by  Marx,  of  New  York,  and  the 
hope  is  that  before  long  every  physician  who  contemplates  the 
induction  of  premature  labor  will  take  steps  to  secure  one  in 
advance. 

This  incubator  consists  of  a  box  made  of  well-seasoned 
hard  wood,  21  inches  long,  20  inches  wide,  and  14.4  inches 
high,  lined  throughout  with  sheet  zinc,  between  which  and  the 


70 


OBSTETRIC     SURGERY. 


wood  is  a  layer  of  sheet  asbestos.  It  is  divided  by  a  partition 
into  two  unequal  portions,  one  of  which,  sliglitly  wider  than  the 
other,  is  the  incubator  proper,  the  other  containing  the  heat- 
generating  apparatus.  This  latter  is  a  copper  boiler  of  the 
capacity  of  one  quart,  resting  on  a  tripod,  underneath  which  is 
a  Bunsen  burner  or  an  alcohol-lamp,  which  supplies  heat  to  the 
water.  Passing  from  the  boiler  through  the  partition  and  wind- 
ing about  the  coils  over  the  V-bottom  of  the  incubator  portion 


Fig.  30.— Marx's  Incubator  (Closed). 

is  a  ^-inch  pipe  about  10  feet  in  length,  terminating  in  a 
free  vent  outside  the  box.  The  steam  thus  received  in  a  suita- 
ble vessel,  condenses  and  gives  us  an  index  of  the  condition  of 
the  boiler.  The  top  of  the  boiler  projects  through  the  box  and 
is  closed  by  a  metal  cap,  which  unscrews  so  that  the  V-boiler 
may  be  readily  replenished  with  water.  In  the  incubator 
proper   there   is   a   well-padded    basket    suspended   so   that  its 


INDUCTION    OF    PREMATURE    LABOR. 


71 


bottom  is  about  5  inches  above  the  coil  of  the  steam-pipe.  A 
glass  plate  sliding  in  grooves  acts  as  a  cover,  which  may  be  par- 
tially or  entirely  withdrawn  to  aid  in  the  ventilation,  which  is 
supplied  by  numerous  holes  drilled  in  the  walls  of  the  box.  A 
thermometer  is  fastened  horizontally  to  the  top  of  the  basket, 
immediately  beneath  the  glass  slide. 

This  simple  apparatus  commends   itself  on  account  of  its 


Fig.  31.— Marx's  Incubator  (Open 


relative  cheapness,  thus  bringing  it  within  the  reach  of  even 
people  of  moderate  means  in  whose  families  the  operation  of  the 
induction  of  premature  labor  becomes  an  operation  of  election. 
Even  so,  we  question  whether,  outside  of  maternity  hospitals 
and  the  homes  of  the  well-to-do,  it  will  often  be  practicable  to 
rear  infants  under  the  thirty-second  week  of  gestation,  in  view 
of  the  necessitv  of  having-  an  attendant  to  watch  the  incubator 
night  and  day. 


CHAPTER   III, 


FORCEPS. 

It  is  not  intended  here  to  enter  into  the  history  of  the 
subject  at  all,  nor  to  describe  the  various  instruments  and  their 
modifications  which  are  in  general  use.  The  special  modifi- 
cation of  the  instrument  is  of  very  much  less  service  than  an 
accurate  knowledge  of  the  use  of  the  instrument.  Uecognizing 
the  fact  that  traction  is  the  essential  power  of  forceps,  it  will 
appear  that  any  instrument  which  is  easily  kept  clean,  easily 
adjusted  to  the  child's  head,  and  which  is  rigid  enough  to  pre- 


Fig.  32.— Elliott  Forceps. 

vent  slipping,  will  be  the  instrument  which  will  meet  the 
greatest  number  of  requirements. 

Numbers  of  instruments  have  been  devised,  which,  though 
not  perfect,  will  so  nearly  meet  these  requirements  as  to  leave 
little  to  be  desired.  A  forceps  which  is  in  very  general  use,  and 
which  is  capable  of  being  adapted  to  a  large  number  of  cases, 
is  Elliott's  (Fig.  32).  This  is  a  long,  well-curved,  and  somewhat 
heavy  instrument,  which  has  an  adjustable  screw  in  the  handle, 
by  means  of  which  the  amount  of  pressure  on  the  head  can  be 
regulated.  While  this  is  a  convenience,  it  is  no  easy  matter  to 
keep  the  screw  aseptic,  and  the  same  end  may  be  gained  by 
placing  a  folded  towel  between  the  handles  of  instruments  not 
furnished  with  this  attachment. 

An  instrument  which  is  not  in  very  general  use,  but  which 
(72) 


FORCEPS. 


73 


undoubtedly  possesses  merit,  is  known  as  Hunter's  (Fig.  33). 
This  instrument,  having  almost  no  handle,  is  grasped  by  means 
of  a  bar  formed  by  the  locking  of  the  two  blades.  A  firm  pur- 
chase is  attained  in  this  way,  and  the  hand  is  so  near  the  head 


Fig.  33.— Hunter  Forceps. 

of  the  child  that  but  little  leverage  force  is  possible.    The  short- 
ness of  the  handles  renders  this  forceps  easy  of  application. 

In  addition  to  possessing  some  instrument  Avhich  will 
meet  the  requirements  mentioned,  the  operator  who  wishes  to 
be  prepared  to  meet  emergencies  must,  of  necessity,  supply  him- 
self with  some  instrument  which  will  permit  him  to  make  use 
of  the  principle  of  axis-traction.    This  can  be  found  best  perhaps 


Fig.  34.— Lusk-Tarnier  Forceps. 

in  the  instrument  as  devised  by  Tarnier  and  modified  by  Lusk 
(Fig.  34).  The  disadvantages  of  this  instrument  are  that  it  is 
heavy  and  adds  an  amount  of  weight  to  the  obstetric  bag  which 
is  objectionable..  It  is  somewhat  expensive,  thus  deterring  some 
from    supplying    themselves  with    it.      The   axis-traction    rods 


74 


OBSTETRIC     SURGERY. 


which  have  been  devised  by  Eeyiiolds  (Fig.  36)  possess  the 
advantages  of  being  light,  taking  up  but  little  room,  and  are 
comparatively  inexpensive.  They  may  be  attached  to  any  pair 
of  fenestrated  forceps.  This  contrivance  consists  of  a  pair  of 
steel  rods,  which  terminate  at  their  upper  ends  in  fiat  buttons  in- 
tended to  engage  in  the  lower  extremity  of  the  fenestra  ;  and  at 
their  lower  ends  in  hooks,  which  are  received  by  rings  connected 
with  a  transverse   traction  handle.      The  appliance  is  perfectly 


Fig.  35. — .Jewetf  s  Axis-Traction  Forceps. 


simple,  and  any  operator  can  easily  apply  it  to  his  ordinary  for- 
ceps. They  may  be  fastened  to  the  forceps-blades  either  before 
or  after  the  blades  have  been  adjusted  to  the  child's  head. 

Traction  is  not  the  only  force  of  which  the  forceps  is  capable, 
for  compression  and  leverage  are  coincident  to  a  greater  or  less 


degree. 


In  order  that  the  forceps  may  not  slip,  a  certain  amount  of 


FORCEPS. 


75 


compression  is  necessary  when  traction  is  being  made.  It  is 
wise  to  remember  this  specially  in  those  cases  where  the  opera- 
tion is  prolonged,  in  order  that  injury  may  not  result  to  the 
child.  From  time  to  time  the  instrument  should  be  unlocked 
and  the  handles  slightly  separated,  thus  liberating  the  foetal 
head.  The  forceps  is  not  used  for  this  compression  force ;  it  is 
simply  an  unfortunate  condition,  without  which  traction  cannot 
be  made.  It  is  better  that  traction  should  be  of  an  intermittent 
character,  if  for  no  other  reason  than  that  the  head  may  be  re- 
lieved of  this  necessary  compression  at  least  every  two  minutes. 
Most  authors  hold  that  any  form  of  leverage  to  be  obtained 


Fig.  36.-=-Showino;  Reynolds's  Traction  Rods  in  Position. 

by  forceps  is  not  only  objectionable,  but  absolutely  harmful. 
The  use  of  the  swinging  or  pendulum  motion  during  traction 
may  easily  result  in  dangerous  consequences  to  the  mother,  and 
should  not  be  attempted.  Without  any  doubt,  a  very  slight 
up-and-down  motion  will  facilitate  the  extraction  ;  but  it  must 
be  borne  in  mind  that,  at  the  same  time,  the  free  ends  of  the 
forceps  may  be  plowing  into  the  maternal  soft  parts. 

Direct  traction  is  fraught  with  so  little  danger  to  the 
mother,  and  will  so  certainly  be  successful  in  those  cases  where 
the  forceps  is  indicated,  that  it  would  be  better  never  to  resort 
to  this  pendulum  motion.  Instrumental  rotation  should  not 
be  attempted,  for  maternal  injury  is  almost  certain  to   result. 


76  OBSTETRIC     SURGERY. 

However,  it  is  necessary  for  the  physician  to  bear  in  mind 
that  if  the  forceps  has  been  appUed  before  rotation  has  taken 
place  he  must  be  careful  not  to  prevent  it  by  rigidly  holding 
his  instrument. 

Indications. — It  would  be  almost  impossible  to  mention  all 
the  indications  for  the  application  of  the  forceps.  In  a  general 
way  it  may  be  said  that  inability  of  the  mother's  expulsive 
forces  to  overcome  the  obstacles  to  delivery  is  one  of  the  most 
frequent  indications. 

Secondly,  any  cause  which  requires  that  the  delivery  should 
be  accomplished  rapidly,  either  in  the  interest  of  the  mother  or 
the  child,  provided,  for  other  reasons,  that  the  forceps  is  not 
contra-indicated,  makes  its  application  justifiable. 

Forceps  should  not  be  applied  to  the  hydrocephalic  head,  a 
decoraposiug  foetus,  nor  npon  a  perforated  head.  If  applied  to 
the  hydrocephalic  head  or  one  that  is  decomposing,  it  will  almost 
certainly  fail  to  hold,  and.  even  if  successful,  the  end  gained  is 
not  commensurate  with  the  risk  of  injury  to  the  mother.  The 
perforated  head  can  be  better  handled  with  a  cephalotribe. 

Forceps  should  not  be  applied  until  the  os  is  three-quarters 
dilated  or  dilatable,  nor  until  the  membranes  have  ruptured  and 
retracted.  If  the  membranes  have  not  retracted,  there  is  the 
possibility  tliat  they  may  be  grasped  by  the  forceps  and  placental 
detachment  occur. 

The  actual  size  of  the  os  is  of  less  importance  than  its 
dilatability.  Forceps  should  not  be  applied  until  the  elasticity 
of  the  cervix  justifies  the  easy  introduction  of  the  blades. 

There  must  be  no  mechanical  obstruction  on  the  part  of 
the  pelvic  canal  which  will  prevent  the  delivery  of  the  child 
without  unusual  force.  Carcinoma  of  the  cervix,  inasmuch  as 
the  cervix  is  rendered  so  pliable,  is  a  contra-indication  to  the 
application  of  forceps. 

Forceps  should  not  be  applied  where  the  foetal  head  and 
the  pelvic  canal  are  so  disproportionate  that  the  probability  of 
delivering  a  live  child  seems  small. 


FORCEPS.  77 

Finally,  forceps  should  not  be  applied  until  the  head  has 
engaged. 

In  regard  to  the  time  which  should  be  allowed  to  elapse 
before  the  obstetrician  resorts  to  instrumental  delivery,  it  must 
be  remembered  that  it  is  a  question  of  conditions,  and  not  min- 
utes or  hours.  Undoubtedly  many  women  would  escape  that 
condition  of  pelvic  relaxation,  which  is  so  often  seen,  following 
tardy  deliveries,  if  forceps  were  used  before  the  muscles  entering 
into  the  pelvic  floor  were  paralyzed  from  overstretching.  As 
soon  as  it  is  evident  that  the  vis  a  tergo  is  not  sufficient  to  over- 
come the  resistance,  then  forceps  should  be  applied.  Another 
very  safe  rule  to  remember  is:  whenever  the  head  fails  to  recede 
after  a  contraction  of  the  uterus,  forceps  should  be  applied. 
The  failure  of  the  head  to  recede  after  a  contraction  shows  that 
undue  pressure  is  being  made  on  the  soft  parts  of  the  pelvic 
canal. 

Ancesthesia. — Although  it  is  probable  that  the  extraction 
of  the  child  with  forceps  is  but  slightly  more  painful  than  nor- 
mal delivery,  yet  it  is  rarely  justifiable  to  apply  forceps  until  the 
patient  is  thoroughly  under  the  influence  of  the  ansesthetic. 
The  danger  Avhich  may  result  from  some  sudden  motion  on  the 
part  of  the  woman  is  greater  than  the  danger  of  the  anaesthetic, 
to  say  nothing  of  the  increased  ease  of  extraction  on  the  part 
of  the  obstetrician.  Chloroform  is  so  much  more  rapid  in  its 
efl'ects,  and  leaves  so  little  to  be  desired  as  an  ansesthetic,  that  it 
is  preferable  to  ether.  The  patient  should  be  anaesthetized  to 
the  surgical  degree  before  the  instrument  is  applied. 

Many  authors  hold  that  the  application  of  forceps  is  only 
justifiable  in  head  presentations.  Undoubtedly  it  will  seldom 
be  necessary  to  apply  it  to  the  breech,  but  there  are  con- 
ditions which  will  render  the  application  of  forceps  to  the  full 
breech  very  advantageous. 

It  is  absolutely  necessary  to  make  a  correct  diagnosis  of 
the  position  of  the  child  and  the  causation  of  the  tardy  natural 
delivery  before  the  application  of  forceps.     Before  the  examina- 


78  OBSTETRIC     SURGERY. 

tion  is  made  which  is  to  determine  these  points,  it  is  better  that 
the  obstetrician  have  everything  in  readiness,  so  that  no  delay 
may  occur.  He  should  see  that  the  usual  heart  stimulants  are 
at  hand.  An  hypodermatic  syringe  and  fluid  extract  of  ergot, 
together  with  other  oxytocics,  should  be  in  readiness.  The  in- 
strument should  be  sterilized  and  placed  in  a  basin  containing 
1  to  100  creolin  solution. 

Inasmuch  as  in  forceps  cases  repeated  digital  examinations 
are  made,  it  is  wise  to  exercise  unusual  care  in  rendering 
the  hands  aseptic.  They  should  be  thoroughly  scrubbed  with 
soap  and  hot  water,  and  afterward  immersed  in  1  to  1000 
bichloride-of-mercury  solution  for  five  minutes.  The  patient 
should  be  anaesthetized  and  turned  across  the  bed  so  that  the 
hips  will  extend  well  over  its  edge ;  the  knees  can  be  held  by 
two  assistants  sitting  on  either  side  of  the  patient.  The  anaes- 
thetic should  be  given  into  the  hands  of  a  physician  who  will 
have  no  other  duty  to  attend  to. 

The  external  genitals  and  vagina  should  be  cleansed  with 
soap  and  water  and  a  soft  scrubbing-brush,  and  afterward 
douched  either  with  1  to  3000  bichloride-of-mercury  solution 
or  1  to  100  creolin  solution. 

After  palpating  the  abdomen,  one  hand  should  be  passed 
into  the  vagina  if  the  head  is  high,  and  witli  two  fingers  the 
operator  should  carefully  palpate  the  fontanelles.  If  there  be 
any  doubt  about  their  relation  to  the  pelvic  canal  he  should 
seek  an  ear,  and  finding  it  will  enable  the  diagnosis  to  be  made 
certainly.  At  the  same  time  he  can  determine  if  any  obstruc- 
tion on  the  part  of  the  mother  exists.  The  foetal  heart-sounds 
should  be  listened  to,  for  their  character  will  enable  him  to  de- 
termine somewhat  the  eftects  of  tardy  delivery  on  the  life  of  tlie 
cliild.  The  forceps  is  usually  applied  wdiile  the  patient  is  on 
her  back,  though  some  prefer  the  left  lateral  posture.  The 
bladder  and  rectum  should  be  emptied  before  any  operative 
procedure  is  undertaken. 

The  operator,  having  assured  himself  of  the  exact  position 


PLATE    IV. 


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Bfc^..^fl 

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P 

^^j^OL 

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■ 

Introduction   of  the   Left    Blade   of  the   Forceps. 


FORCEPS. 


79 


of  the  child's  head,  and  that  there  are  no  contra-indications  to 
delivery  by  the  forceps,  proceeds  to  apply  it. 

The  blades,  for  purposes  of  designation,  are  known  as  right 
and  left,  corresponding  to  the  right  and  left  sides  of  the  pelvic 
canal.  The  left  blade  should  be  introduced  first  on  account  of 
the  method  of  locking.  The  left  blade,  grasped  near  the  handle 
with  the  left  hand,  is  introduced  into  the  vagina  (Plate  IV  and 
Fig.  37).  Two  or  more  fingers  of  the  right  hand  passed  into 
the  vagina  until  the  head  is  felt  will  serve  as  a  guide  to  its 


Fig.  37.— Introduction  of  the  Left  Blade  of  the  Forceps. 


introduction.  The  blade  is  made  to  glide  along  the  palmar 
surface  of  the  right  hand  and  pass  between  the  fingers  of  that 
hand  and  the  head.  It  is  necessary  to  remember  the  two 
curves  of  the  forceps  in  introducing  it.  As  the  blade  passes 
tlie  fingers  the  handle  is  to  be  depressed  and  carried  slightly 
outward.  At  no  time  must  force  be  used  in  its  introduction. 
If  the  blade  cannot  be  made  to  easily  adjust  itself,  it  is  better 
to  withdraw  it  entirely  and  make  another  attempt.  Force  is  so 
certain  to  do  injury  to  the  soft  parts  that  it  is  never  justifiable. 
After  the  left  blade  has  been  introduced  its  handle  should 


80 


OBSTETRIC     SURGERY. 


be  given  into  the  hands  of  an  assistant,  and  the  right  blade  in- 
troduced. Here  the  left  hand  acts  as  the  guide  and  the  right 
hand  manages  the  blade  (Fig.  38).  No  attempt  should  be  made 
to  introduce  the  blades  during  a  contraction  of  the  uterus. 

It  is  customary  to  apply  the  blades  first  to  the  sides  of  the 
pelvis,  irrespective  of  the  position  of  the  cliild's  head,  and  after- 
ward, if  possible,  have  them  grasp  the  child's  head  in  its 
biparietal  diameter.  As  soon  as  the  blades  are  passed  and 
adjusted,  they  should  be  locked  (Fig.  39).  This  is  usually  ac- 
complished easily  by  slightly  depressing  both  handles.     Should 


Fig.  38.— The  Left  Blade  Introduced ;  the  Right  Blade  (in  Outline^  Ready  to  be 

Introduced. 

this  not  accomplish  the  desired  end  they  may  be  advanced  or 
slightly  withdrawn,  and  another  attempt  made  to  lock  them. 
Forced  locking  must  not  be  attempted.  The  very  fact  that  the 
blades  will  not  easily  lock  indicates  that  there  is  eitlier  faulty 
application  or  else  the  case  is  not  one  in  which  forceps  should 
be  used. 

There  is  no  operation  which  calls  for  more  gentleness, 
judgment,  and  patience  than  the  application  of  forceps.  It  is 
always  necessary  to  bear  in  mind  the  possibility  of  including  the 


FORCEPS 


81 


mother's  soft  parts  in  the  grasp  of  the  forceps,  and  the  injury 
which  would  result  therefrom. 

It  is  necessary  to  study  the  subject  of  forceps  operations  in 
their  various  phases,  inasmuch  as  they  each  present  their  own 
peculiarities. 

The  operations  may  be  divided  into  low,  medium,  and  high 
applications.  Again,  whether  the  occiput  is  anterior  or  pos- 
terior, and  whether  the  liead  is  proportionate  to  the  pelvic  canal 
or  not. 

Tlie  Application  of  Loio  Forceps^  Occipito-anterior  Position^ 


Fig.  39.— The  Forceps  Adjusted  and  Ready  to  be  Locked. 

Head  and  Birth-Canal  ProjMrtiouate. — This  operation  is  the 
most  simple  of  all  forceps  deliveries.  It  is  indicated  when  for 
any  reason  it  is  an  advantage  to  mother  or  child  that  the  labor 
be  terminated.  These  are  the  cases  where  non-interference  so 
often  results  in  injury  to  the  mother's  pelvic  floor,  the  head 
remaining  on  the  pelvic  floor  for  so  long  a  time  that  the  levator 
ani  muscle  and  the  triangular  ligaments  are  not  able  to  regain 
their  tonicity  after  the  labor  and  their  diaphragmatic  action  is 
impaired. 


82  OBSTETRIC     SURGERY. 

It  must  be  borne  in  miDcl  that  the  abdommal  muscles  play 
bv  far  the  greater  part  in  the  act  of  expelling  the  head  from  the 
vulva,  and  in  women  of  poor  muscular  development  or  in  those 
who  have  become  thoroughly  exhausted  from  a  prolonged  first 
stase  the  muscular  force  necessarv  to  expel  the  head  may  be 
wanting.  Many  of  these  women  would  undoubtedly  deliver 
themselves  if  left  alone ;  but  the  question  arises  whether  or  not 
thev  will  not  suffer  more  injury,  and  of  a  more  permanent  char- 
acter, if  unaided,  than  could  possibly  result  from  the  application 
of  low  forceps.  It  is  not  intended  by  this  to  mean  that  every 
woman  should  be  delivered  with  forceps  as  soon  as  the  head  is 
low  down,  but  simply  as  an  opinion  that  many  women  are  per- 
manentlv  injured  by  reason  of  an  unnecessarily  prolonged  second 
stao-e. 

Under  strict  aseptic  precautions,  as  already  mentioned,  the 
blades  are  applied  over  the  biparietal  diameter  of  the  child's 
head.  As  soon  as  locking  has  been  accomplished,  it  is  well  to 
make  tentative  traction  to  see  that  they  have  a  firm  grasp. 

The  instrument  should  be  grasped  with  the  right  hand, 
with  palmar  surface  downward.  Should  the  instrument  have 
transverse  shoulders,  the  index  and  middle  fingers  should  be 
placed  over  one  shoulder  and  the  remaining  fingers  over  the 
other.  In  using  Hunter's  forceps  it  is  often  a  relief  to  place  a 
towel  over  the  cross-bar  and  with  the  right  hand  grasp  the 
towel.  (Plate  Y,  Fig,  1.)  The  left  hand  should  be  placed 
ao'ainst  the  patient's  buttocks,  with  one  finger  'over  the  four- 
chette.  This  will  enable  the  operator  to  determine  just  how 
much  force  he  is  exerting  on  the  perineum.  Traction  should 
be  made  downward,  or  as  nearly  so  as  the  perineum  will 
permit,  thus  accentuating  flexion  (Fig.  10).  Pendulum  or 
swinging  force  during  traction  is  contra-indicated.  Firm  trac- 
tion exerted  for  not  more  than  one  minute  will  accomplish  the 
extraction  if  persisted  in.  It  should  be  the  operator's  attempt 
to  imitate  nature  as  nearly  as  possible  in  preparing  the 
perineum  for  the  delivery  of  the  head.      This  can  be  done  by 


PLATE    Y. 


Fig.    I. — Towel    Applied    to    Handle   of    Hunter  s    Forceps. 


Fig.    2. — Bilateral    Incision   of  the    Perineum    (Eplslotomy). 


FORCEPS. 


83 


allowing  the  head  to  recede  after  each  traction.  He  should 
also  release  the  grasp  of  the  forceps  slightly  at  each  recession, 
that  the  child  may  not  be  injured. 

In  the  majority  of  cases  calling  for  instrumental  extraction 
pains  are  so  infrequent  that  it  is  not  wise  for  the  operator  to 
wait  lor  the  help  which  uterine  contractions  may  give  him,  but 
he  should  make  traction  irrespective  of  their  presence.  AVell- 
directed  abdominal  pressure  on  the  part  of  an  assistant  will  be 
of  undoubted  value.  If  it  is  evident  that  perineal  laceration  is 
impending,  it  is  better  to  at  once  perform  episiotomy.  This 
little  operation  is  no  doubt  worthy  of  more  consideration  than 
it  has  ever  received.     The  measure  is  a  simple  one,  consisting 


Fig.  40.— Showing  the  Direction  of  the  Line  of  Traction. 

only  in  relieving  the  strain  on  the  perineum  by  making  a 
lateral  incision  on  either  side  of  the  vulvar  orifice.  (Plate  V, 
Fig.  2.)  The  incision  need  not  be  more  than  an  eighth  of  an 
inch  in  depth  and  half  an  inch  long,  extending  up  into  the 
vagina.  It  is  not  likely  that  haemorrhage  of  any  consequence 
will  result  from  this  procedure,  but,  even  if  it  should,  a  con- 
tinuous catgut  stitch  will  control  it  without  difficulty. 

As  soon  as  the  occiput  is  brought  well  down  underneath 
the  pubic  arch,  the  forceps  should  be  removed  and  the  head 
delivered  between  pains,  by  introducing  the  finger  into  the  rec- 
tum and,  finding  the  chin,  tilting  it  out  over  the  perineum.  As 
soon  as  the  head  is  delivered   it   should  be   held  so  that  the 


84  OBSTETRIC     SURGERY. 

shoulders  may  not  be  driven  through  the  vulvar  outlet  during  a 
pain ;  but  as  soon  as  the  contraction,  which  is  nearly  always  ex- 
cited by  the  delivery  of  the  head,  has  subsided,  they  may  be 
Ufted  out  as  was  the  head. 

Low  Forceps  in  Occipito-posterior  Position^  ivltJi  Partial 
Rotation. — It  has  been  shown  that  firm  uterine  contractions, 
forcing  the  foetus  to  travel  over  the  inclined  planes  of  the  pelvis 
and  resisted  by  a  firm  perineum,  will  cause  the  occiput  to  rotate 
forward.  Should  any  of  these  factors  be  absent  rotation  may 
not  be  complete,  and  the  foetus  will  occupy  an  oblique  position 
with  occiput  posterior.  Usually,  by  giving  the  mother  a  rest, 
firm  contractions  will  ensue  and  anterior  rotation  and  normal 
delivery  take  place.  It  often  happens,  however,  that  in  the 
interest  of  mother  or  child  instrumental  delivery  becomes 
necessary. 

After  a  very  careful  examination,  so  that  the  exact  position 
of  the  occiput  is  made  out,  forceps  should  be  applied  in  one  of 
two  ways :  either  directly  to  the  sides  of  the  pelvis  or  else  in  an 
oblique  position. 

The  latter  is  more  difficult,  but  is  preferable  on  account  of 
the  lessened  risks  to  the  child.  The  forceps  shoirld  be  applied 
in  that  oblique  diameter  which  is  not  occupied  by  the  head. 
This  will  cause  the  blades  to  grasp  the  biparietal  diameter  of 
the  head.  The  rule  that  the  left  blade  should  be  introduced 
first  should  be  disregarded  here,  unless  it  be  at  tlie  same  time 
the  anterior  blade,  for  this  is  tiie  difficult  one  and  should  be  first 
introduced.  Unusual  care  must  be  taken  to  guard  the  mother's 
soft  parts  from  injury.  The  forceps  should  be  unlocked  after 
each  traction,  which  not  only  lessens  the  danger  to  the  child, 
but  also  by  releasing  the  head  permits  rotation  to  take  place. 
At  no  time  must  instrumental  rotation  be  attempted,  nor,  on 
the  other  hand,  must  natural  rotation  be  prevented.  Oftentimes 
it  is  wise  to  remove  the  forceps  altogether  and  re-adjust  it 
over  the  biparietal  diameter,  which  may  have  changed  its  po- 
sition.    By  patience  and  absence  of  any  desire  on  the  part  of 


FORCEPS.  85 

the  operator  to  hasten  the  rotation,  the  head  will  often  gradu- 
ally mold  itself,  and  under  the  tractions  of  the  forceps,  which 
acts  as  a  re-inforcement  to  the  expellant  forces,  rotate  anteriorly. 

If,  after  patient  and  gentle  efforts,  it  be  impossible  to  adjust 
the  forceps  over  the  biparietal  diameter,  it  should  be  applied 
directly  to  the  sides  of  the  pelvis.  The  same  care  must  be 
exercised  here  that  the  mother's  soft  tissues  are  not  injured.  It 
is  also  imperative  that  tractions  should  not  be  prolonged  longer 
than  a  minute,  and  that  the  grasp  of  the  forceps  be  relaxed 
between  tractions.  The  child  is  put  to  such  a  disadvantage, 
even  under  these  circumstances,  that  its  life  is  often  seriously 
jeopardized  and  the  operation  is  done  primarily  in  the  interest 
of  the  mother. 

Low  Forceps  in  Occipito-posterior  Position. — It  is  the  gen- 
eral opinion  among  obstetricians  tliat  few  abnormalities  produce 
a  more  difficult  condition  to  terminate  successfully  than  those 
cases  where  the  occiput  has  rotated  posteriorly  and  is  wedged 
in  the  hollow  of  the  sacrum.  Fortunately  they  are  not  very 
frequent,  for  the  child's  condition  is  most  perilous  and  injury  to 
the  mother's  soft  parts  almost  certain. 

It  is  far  better  to  delay  the  application  of  forceps  in  these 
cases  as  long  as  possible,  that,  under  continued  uterine  contrac- 
tions, anterior  rotation  may  occur.  If,  however,  the  mother  is 
showing  signs  of  exhaustion,  or  if  the  foetal  heart  become 
feeble,  then  there  is  no  other  resort  but  to  apply  forceps.  Delay 
beyond  this  point  is  not  admissible. 

The  patient  should  be  anaesthetized  and  the  parts  rendered 
aseptic,  as  before  suggested.  Carefully  guarding  the  soft  parts, 
the  blades  are  applied  to  either  side  of  the  child's  head.  A 
moderate  amount  of  pressure  is  necessary  to  prevent  the  blades 
slipping,  but  by  relaxing  the  grasp  frequently  the  injury  to  the 
child  will  be  greatly  lessened.  As  soon  as  the  forehead  is  made 
to  appear  beneath  the  pubic  arch  it  is  well  to  remove  the  for- 
ceps, and,  unless  the  reasons  for  immediate  extraction  are 
urgent,  it  is  well  to  give  nature  a  chance  to  rotate  the  occiput 


86 


OBSTETPJC     SURGERY. 


aiiteriorlv,  Otherwise,  in  place  of  making  traction  liorizontally. 
as  IS  necessary  when  bringino-  the  foreliead  underneatli  the 
piibic  arch,  the  handles  should  be  lowered  as  far  as  the  peri- 
neum will  permit.  This  manoeuvre  will  cause  marked  extension 
of  the  head  and  the  forehead  will  be  brought  underneath  the 
pubic  rami.  Forced  extension  now  will  cause  the  forehead  to 
clear  tlie  pubes.  The  forceps  should  now  be  removed  and,  pass- 
ins  two  fino-ers  into  the  rectum,  the  liead  should  be  flexed  until 
the  occiput  escapes  over  the  perineum. 

Laceration  of  the  perineum  will  be  almost  certain  to  occur, 
and  it  should  be  repaired  at  once. 


Fig.  41. — Sliowing  Direction  of  Traction  in  Face  Presentation. 

As  already  stated,  tliese  cases  are  among  the  most  diffi- 
cult ones  found  in  obstetrics,  and  one  of  the  liardest  things  to 
resist  is  the  desire  to  attemyjt  instrumental  rotation.  It  will 
only  be  necessary  to  remember  to  what  unusual  risks  this  will 
subject  the  mother,  to  deter  one  from  this  procedure. 

io'//;  Forcej^js  In  Face  Presentatioii-s. — The  application  of 
forceps  in  face  presentations,  when  that  condition  has  not  been 
diagnosed  until  after  the  face  is  well  down  in  the  pelvic  canal, 
sliould  be  delayed  as  Ions'  as  is  consistent  with  the  safety  of 
mother  and  child,  in  order  that  anterior  rotation  of  the  chin 
may  occur.  This  rotation  is  nearly  always  tardy,  and  some- 
times does  not  take  place  at  all.  Manual  rotation  of  the  liead. 
if  not  too  firmly  wedged,  is  permissible  and  sometimes  success- 


FORCEPS.  87 

fill,  but  at  no  time  should  forceps  be  used  to  bring  about  this 
rotation.  If  the  chin  has  rotated  anteriorly,  forceps  should  be 
applied  directly  to  the  sides  of  the  child's  head.  A  firm  grasp 
must  be  taken  and  some  compression  used  to  prevent  the  blades 
slipping.  Traction  should  be  made  horizontally  until  the  chin 
is  brought  underneath  the  pubic  arch,  when  the  handles  should 
be  raised  and  the  cranial  vault  and  occiput  lifted  over  the  peri- 
neum. If  the  chin  is  turned  posteriorly  and  the  head  is 
wedged  in  the  pelvic  outlet,  there  is  so  little  probability  that  a 
living  child  can  be  extracted  that  it  seems  to  be  the  part  of 
conservative  treatment  to  turn  the  attention  entirely  to  the  wel- 
fare of  the  mother  and  do  craniotomy,  or,  in  favorable  cases, 
symphysiotomy. 

Forceps  in  Breecli  Presentations. — Forceps  shoidd  not  be 
applied  to  the  breech  until  after  it  has  firmly  engaged.  When, 
however,  the  breech  has  entered  the  pelvic  canal,  and  yet  is 
too  high  to  permit  the  finger  passing  over  the  groin  or  the 
application  of  the  fillet,  Tarnier's  axis-traction  forceps  will  be 
most  advantageous.  A  dilated  or  dilatable  os  will  render  the 
operation  so  much  more  easy  of  success  that  this  should  be 
accomplished  before  the  application  of  forceps.  The  majority 
of  these  cases  are  met  in  old  primiparse,  where  the  parts  are  more 
than  usually  rigid,  and  the  time  spent  in  dilating  the  cervix  will 
not  be  wasted.  If  rotation  has  occurred,  the  blades  should  be 
applied  over  the  sacrum  and  posterior  aspect  of  the  thigh. 

It  is  here  that  caution  will  be  necessary  to  prevent  the 
blades  impinging  so  firmly  on  the  parts  that  the  child  will  be 
injured,  and  at  the  same  time  firmly  enough  so  that  they  will 
not  slip  and  injure  the  mother's  soft  parts.  Hence  it  is  better 
to  make  tentative  traction  at  first,  to  see  that  the  grasp  is  firm. 
The  application  of  the  principle  of  axis-traction  to  forceps 
enables  the  operator  to  use  very  much  less  force  in  the  extrac- 
tion, inasmuch  as  the  resistance  caused  by  the  pressure  of  the 
presenting  part  against  the  anterior  pelvic  wall  is  very  much 
lessened.     Traction  should  be  made  only  during  a  contraction 


OBSTETRIC     SURGERY. 


of  the  uterus,  unless  the  pahis  be  too  hifrequent.  If  this  should 
be  the  case,  it  is  better  to  imitate  the  methods  of  nature  and 
permit  the  recession  of  the  breech  after  each  traction.  The 
rigidity  of  the  canal  will  rapidly  lessen  under  the  influence  of 
the  advance  of  the  breech,  and  the  integrity  of  the  soft  parts  will 
more  likely  be  preserved. 

If  this  intermittent  traction  is  used,  a  very  small  amount  of 
force  will  accomplish  the  delivery  of  the  breech.  Should  the 
hips  be  transverse,  it  is  better  to  attempt  manual  rotation  first. 
If  this  is  not  possible,  then  the  blades  should  be  applied  to  the 


Fig.  42.— Tanner  Forceps  Applied  to  the  Tliiglis. 

lateral  surfaces  of  the  thighs  (Fig.  42).  It  is  not  expedient 
to  allow  the  blades  to  embrace  the  crests  of  the  ilia,  inasmuch 
as  tlie  bones  are  too  compressible  and  the  forceps  is  almost  cer- 
tain to  slip.  In  all  cases  well-directed  pressure  over  the  fundus 
will  greatly  facilitate  the  extraction. 

The  Application  of  Medium  Forceps. — Most  authors  refer 
to  all  forceps  operations  above  the  inferior  strait  as  high  forceps, 
and  confuse  in  this  way  two  very  difl'erent  operations.  When 
the  head  has  firmly  engaged,  indicating  that  its  greatest  diameter 
has  entered  the  pelvic  inlet,  it  seems  better  to  consider  it  as 
being  in  a  medium  position,  and,  should  it  become  arrested  there 


FORCEPS. 


89 


and  necessitate  extraction,  to  call  the  operation  medium  forceps. 
This  condition  depends  either  on  the  disproportion  of  the  head 
and  the  birth-canal  or  on  lack  of  uterine  force  to  overcome  the 
resistance  which  is  normally  present. 

This  operation  is  fraught  with  far  more  danger  than  low 
forceps,  for  the  blades  of  the  instrument  must  of  necessity  enter 
the  lower  uterine  segment,  when  the  most  extreme  caution  will 
be  necessary  to  prevent  injury  to  the  uterus.  Hence  it  is  ad- 
visable to  delay  the  application  of  forceps  until  instrumental 
delivery  seems  imperative  to  the  mother  or  child,  or  both.  If 
the  undilated  cervix  is  preventing  the  advancement  of  the  head. 


Fig.  43.— Incision  of  the  Cervix. 


it  is  far  better  to  manually  dilate  it  than  to  use  the  forceps  as  a 
dilating  force,  as  is  advised  by  many.  Should  cicatrization  from 
any  cause  render  the  cervical  tissue  non-dilatable,  the  little  pro- 
cedure of  nicking  the  cervical  ring,  as  will  be  described  in  the 
chapter  on  "Version,"  will  greatly  facilitate  the  dilatation.  In 
a  recent  case,  where  there  was  a  distinct  history  of  diphtheritic 
vaginitis  in  early  childhood,  one  of  the  authors  encountered  this 
condition  very  markedly  pronounced.  The  head  was  firmly 
engaged  and  it  was  with  difficulty  that  one  finger  could  be  in- 
troduced into  the  os,  although  the  woman  had  been  in  labor 
twentv-four  hours. 


90 


OBSTETRIC     SURGERY, 


After  making  five  or  six  shallow  cuts  through  this  hard- 
ened ring,  manual  dilatation  was  completed  in  eleven  minutes. 
This  procedure  is  fraught  with  no  danger  to  the  child  and  less 
to  the  mother  than  when  dilatation  is  accomplished  hy  alter- 
nately drawing  the  head  down  and  allowing  it  to  recede.  If 
the  delay  in  advancement  is  due  to  lack  of  uterine  force,  this 
organ  will  often  resume  its  energy  if  the  patient  is  given  a  small 
dose  of  quinine, — 5  to  10  grains.  Should  it  become  necessary, 
however,  to  apply  forceps,  the  most  strict  aseptic  precautions 
will  be  necessary.  The  patient  should  be  completely  anaes- 
thetized and  prepared,  as  has  already  been  stated.  The  opera- 
tor should  be  certain  that  the  blades  do  not  embrace  any  of  the 


Fig.  44. — Application  of  iledium  Forceps. 

cervical  tissue  in  their  grasp.  This  can  be  prevented  by  recog- 
nizing the  exact  relation  of  the  cervix  to  the  child's  head,  and 
permitting  the  blade  to  enter  the  lower  uterine  segment  be- 
tween the  fingers  and  the  fcetal  head. 

Medium  forceps  is  usually  applied  directly  to  the  sides  of 
the  pelvis  (Fig.  44).  Axis-traction  forceps  in  these  cases  can 
certainly  accomplish  more  with  less  force  tlian  any  other  instru- 
ment. Although,  in  the  majority  of  cases,  when  the  forceps  is 
thus  applied,  it  will  be  found  that  the  blades  have  grasped  the 
head  in  its  oblique  diameter,  yet  if  the  grasp  of  the  forceps  is 
frequently  relaxed  the  injury  to  the  child  will  not  be  great.  As 
the  head  advances  under  tlie  influence  of  axis-traction  anterior 


FORCEPS.  91 

rotation  will  probably  occur,  and  the  free  mobility,  which  is 
insured  by  the  handle  of  the  traction  rod,  will  permit  this  rota- 
tion more  certainly  than  if  the  ordinary  long  forceps  is  used. 

As  soon  as  the  head  has  been  brought  down  to  the  floor 
of  the  pelvis,  it  is  better  to  remove  the  axis-traction  instrument, 
and,  if  it  is  necessary  to  extract,  complete  the  operation  with 
the  ordinary  forceps.  If  the  axis-traction  forceps  be  not  at 
hand,  and  the  ordinary  forceps  be  used,  the  operator  must  make 
traction  as  nearly  downward  as  the  perineum  will  permit,  bear- 
ing in  mind  at  the  same  time  that  the  pelvic  curve  of  the 
blades  may  be  making  undue  pressure  against  the  anterior 
aspect  of  the  uterus.  At  the  same  time,  if  the  handles  are 
raised  the  presenting  part  will  simply  be  forced  against  the 
symphysis  and  further  advancement  be  prevented.  Hence  it 
will  be  necessary  to  exercise  unusual  patience,  and  at  no  time 
attempt  to  dislodge  the  head  by  the  application  of  brute  force. 

High  Forcejys. — It  has  already  been  stated  that  while  the 
head  is  movable  above  the  brim  forceps  should  not  be  applied. 

In  rare  cases  where  the  waters  ha-se  drained  away  and  the 
uterus  has  firmly  contracted  around  the  foetus,  rendering  ver- 
sion impossible,  simply  as  a  tentative  measure  forceps  may  be 
applied. 

It  is  needless  to  say  that  the  very  greatest  care  must  be 
taken,  or  else  serious  if  not  fatal  injury  to  the  mother  will 
result.  The  patient  should  be  thoroughly  ansesthetized  and 
the  entire  hand  gently  introduced  into  the  vagina.  It  must  be 
remembered  that  after  uterhie  retraction  has  taken  place  the 
possibility  of  rupture  is  increased  and  no  harsh  measures  must 
be  adopted.  It  should  be  the  aim  of  the  obstetrician  to  deter- 
mine, if  possible,  the  cause  of  the  failure  of  the  head  to  engage. 
If  it  is  due  to  contraction  of  the  pelvis  to  any  marked  extent,  it 
will  be  useless  to  attempt  to  drag  the  head  into  and  through 
the  pelvic  canal.  If  the  true  conjugate  is  less  than  three  and 
three-fourths  inches,  with  a  normally-developed  foetus  at  full 
term,  forceps  should  not  be  used. 


92  OBSTETRIC     SURGERY. 

If  upon  examination  the  pelvic  canal  be  normal,  and  it  is 
found  that  early  loss  of  waters  has  taken  place  and  that  uterine 
contractions  have  not  been  of  normal  force,  then  the  forceps 
may  be  applied  while  the  head  is  still  above  the  brim  if  version 
be  contra-indicated.  As  in  medium  forceps,  tlie  cervix  must  be 
dilated  before  the  forceps  is  applied.  Carefully  guarding  the 
blade  with  tlie  right  hand,  the  left  blade  should  be  introduced. 
No  force  must  be  used,  and  if  the  blades  cannot  be  adjusted  to 
the  sides  of  the  pelvis  without  force  the  operation  should  be 
discontinued.  If,  however,  they  can  be  applied,  only  gentle 
force  must  be  used  to  see  if  the  head  can  be  made  to  engage. 
Axis-traction  forceps  should  be  used.  Should  the  head  engage, 
the  after-con ductimi  of  the  case  will  be  the  same  as  in  medium 
forceps. 

Progiiof^is. — The  application  of  low  forceps  should  be  at- 
tended with  absolutely  no  mortality  to  either  mother  or  child. 

When  the  head  has  firmly  engaged,  yet  has  not  descended 
into  the  pelvis,  forceps,  when  applied  under  the  rules  of  asepsis 
already  given,  should  not  be  attended  by  a  mortality  to  the 
mother,  and,  where  there  is  no  malposition  or  disproportion, 
should  be  alike  safe  to  the  child. 

In  the  high  operation,  where  the  head  is  yet  above  the 
brim,  the  prognosis  for  both  mother  and  child  is  very  much  less 
satisfactory.  Extensive  laceration  of  the  soft  parts  and  even 
rupture  of  the  uterus  may  occur.  Experienced  operators  hesi- 
tate before  applying  high  forceps,  realizing  the  great  risk  to  the 
patient.  Tlie  outlook  for  the  child,  on  account  of  the  prolonged 
compression  of  the  head,  is  even  more  serious.  Although  the 
frequent  unlocking  of  the  blades  will  afford  a  greater  degree  of 
safety  to  the  child,  its  life  not  only  is  often  jeopardized,  but 
injury  to  the  cranium  may  result  in  fatal  convulsions  or  epilepsy. 


CHAPTER   IV. 
VERSION. 

The  term  "  version"  applies  to  all  operative  methods  for 
changing-  the  relation  between  the  long  axis  of  the  child  and 
the  long  axis  of  the  uterus. 

Inasmuch  as  version  is  but  another  expression  for  turning, 
it  also  embraces  the  operation  for  converting  an  occipito-posterior 
position  into  an  anterior  one  while  the  child  is  in  utero,  even 
though  the  long  axes  of  the  child  and  the  uterus  remain  un- 
changed. By  means  of  this  operative  interference  the  cephalic 
or  pelvic  pole  may  be  caused  to  present.  The  breech  may  be 
changed  for  the  head,  the  head  for  the  breech,  or  a  transverse 
either  to  the  breech  or  head. 

Again,  as  is  stated  above,  the  back  of  the  child  may  be 
turned  toward  the  abdomen  of  the  mother.  Before  any  opera- 
tive procedure  is  performed  it  is  absolutely  necessary  to  deter- 
mine the  exact  relationship  which  tlie  child  bears  to  the  uterus; 
also  the  mechanical  obstruction  which  is  to  be  overcome,  and 
an  estimate  of  the  comparative  size  of  the  child's  head  and  the 
pelvic  outlet. 

Ordinarily  this  can  be  determined  by  abdominal  palpation 
and  vaginal  examination,  both  of  which  methods  should  be  re- 
sorted to.  External  palpation  is  a  procedure  too  seldom  used, 
and  those  who  will  accustom  themselves  to  study  every  obstetri- 
cal case  in  this  way  will  be  surprised  to  see  how  soon  experience 
will  yield  happy  results.  It  is  so  very  important  to  know 
just  what  position  the  cliild  is  in,  that  if,  as  is  sometimes  the 
case,  it  is  impossible  to  gain  the  proper  information  from  tliese 
two  methods  of  examination,  it  is  better  to  introduce  the  hand 
into  the  vagina  and  one  or  two  fingers  through  the  os.  In  tliis 
way  a  positive  diagnosis  can  be  made.  At  the  same  time  other 
valuable  information  can  be  gained,  viz.,  the  absence  or  character 

(93) 


9-i  OBSTETRIC     SURGERY. 

of  the  pulsation  of  the  cord;  the  low  implantation  of  the 
placenta,  if  such  be  the  case;  the  normal  or  otherwise  promi- 
nence of  the  sacral  arch,  and,  in  cases  of  slightly  deformed 
pelves,  whetlier  or  not  one  or  both  of  the  pubic  rami  encroach 
on  the  pelvic  outlet.  It  is  necessary  to  determine  as  nearly  as 
possible  all  tliese  conditions,  or  else  there  will  be  far  too  many 
cases  of  perforation  of  the  after-coming  head,  with  the  too  late 
realization  that  the  case  was  not  one  on  which  version  should 
have  been  performed. 

The  multiplication  of  terms  is  so  prolific  a  source  of  con- 
fusion in  the  study  of  any  subject,  that  it  seems  wise  to  reduce 
the  nomenclature  of  version  to  such  simplicity  as  is  compatible 
with  clearness. 

Cephalic  version  indicates  that  some  other  position  has 
been  changed  so  that  the  head  presents. 

Pelvic  version  indicates  that  some  other  position  has  been 
changed  so  that  the  breech  presents.  Podalic  version  is  a  term 
which  should  be  included  under  the  head  of  pehic  version, 
inasmuch  as  it  is  but  a  step  farther  in  that  procedure. 

Internal  rotation  of  the  child  is  the  term  which  signifies 
that,  while  the  long  axis  of  the  child  bears  the  same  relationship 
to  the  long  axis  of  the  uterus,  the  occiput  lias  been  made  to 
undergo  a  half-rotation. 

This  changing  of  the  fcetal  relationship  to  the  uterine  may 
be  accomplished  in  three  ways:  External,  internal,  or  com- 
bined external  and  internal  manipulation.  Hence',  to  sum  up 
this  simplification  of  the  nomenclature  as  applied  to  version,  it 
may  be  taken  for  granted  that  all  versions  are  either  cephalic, 
pelvic,  or  internal  rotation  of  the  child,  and  that  the  operation 
is  performed  either  by  external,  internal,  or  combined  external 
and  internal  manipulation. 

Cephalic  version  has  found  a  few  advocates  and,  theoretic- 
ally, should  be  performed  in  all  breech  or  transverse  presenta- 
tions where  no  complications  exist  to  contra-indicate  such  a 
procedure.    Pinard,  who  perliaps  has  done  more  than  any  other 


VERSION.  95 

to  popularize  cephalic  Aversion,  intimates  that  any  other  than  a 
head  presentation  is  due  to  some  abnormal  accommodation  be- 
tween the  head  and  the  pelvic  inlet.  Granting  this  to  be  true, 
it  would  seem  that  this  very  fact  would  contra-indicate  the 
operation.  So  rarely  will  the  patient  be  able  to  deliver  herself, 
even  after  the  cephalic  version  has  been  performed,  that  the 
operation  is  not  to  be  regarded  as  practical  except  in  a  very 
limited  number  of  cases. 

Almost  the  only  condition  which  renders  cephalic  version 
practicable  is  in  transverse  positions,  where  the  waters  have  not 
escaped.  The  operation  is  contra-indicated  in  all  cases  where 
a  rapid  termination  of  the  labor  is  indicated,  when  the  child 
is  not  freely  movable  in  utero,  and  in  prolapse  of  the  cord. 
Should  the  operation  be  determined  upon  in  cases  of  transverse 
position,  as  indicated  above,  the  combined  method  of  Braxton 
Hicks  is  far  more  likely  to  be  successful  than  either  the  external 
or  internal  alone,  Cldoroform  anaesthesia  should  be  produced 
and  the  patient  placed  on  a  table  which  has  been  properly 
covered  and  protected.  The  operator  and  his  assistant  must 
exercise  absolute  care  in  cleansing  their  hands  and  arms.  The 
patient's  bladder  should  be  emptied  and  a  rectal  enema  given. 
The  external  genitals  and  vagina  should  be  cleansed  with  soap 
and  water  by  means  of  a  brush  and  afterward  douched  with 
some  antiseptic  solution,  such  as  bichloride-of-mercury  solution 
1  to  1000,  or  creolin  solution  1  to  100.  The  prone  lithotomy 
position  will,  perhaps,  render  the  operation  least  difficult.  The 
patient  being  in  the  condition  of  surgical  angesthesia,  the  operator 
proceeds  to  carefully  palpate  the  abdomen  and  determine  the 
position  of  the  child.  The  operator  now  redisinfects  his  hand 
and,  selecting  the  one  which  he  most  frequently  uses  in  making- 
vaginal  examinations,  introduces  the  hand  into  the  vagina.  If 
the  OS  is  dilated  sufficiently  to  admit  the  first  and  second  fingers, 
they  are  carefully  passed  througli  the  cervix,  using  as  little  force 
as  is  possible,  so  that  the  membranes  may  not  be  ruptured.  If 
the  OS  is  not  dilated  it  will  be  necessary  to  gradually  introduce 


96  OBSTETRIC     SURGEKY. 

one  finger,  and,  as  soon  as  possible,  the  second.  By  slowly  sep- 
arating the  lingers  as  much  as  possible  enough  room  can  soon 
be  aained  so  that  the  fingers  can  be  passed  into  the  uterus. 
Should  a  contraction  of  the  uterus  take  place  the  operator  will 
desist  from  any  manipulation  in  order  that  the  integrity  of  the 
membranes  may  not  be  endangered.  The  fingers  now  seek  the 
presenting  part,  and  if  it  be  a  shoulder  it  is  gradually  raised  and 
pushed  toward  the  breech.  The  assistant  at  the  same  time 
pushes  the  head  toward  the  pelvic  inlet,  while  with  the  other 
hand  the  operator  governs  the  movements  of  the  breecli,  push- 
ing it  up  toward  the  fundus.  As  soon  as  the  head  impinges  on 
the  vaginal  fingers  it  may  be  made  to  settle  into  the  brim  of  the 
pelvis.  Carefully  controlling  the  body  of  the  cliild  so  that  it 
may  not  again  assume  the  transverse  position,  the  membranes 
are  ruptured  and  the  water  allowed  to  escape.  This  permits 
the  uterus  to  contract  more  firmly  on  the  body  of  the  child,  and 
thus  retains  the  head  in  its  proper  position.  The  remainder  of 
the  delivery  may  now  be  left  to  nature  unless  some  further 
indication  presents  itself. 

Pelvic  version  is,  as  already  stated,  the  term  applied  to  the 
operation  of  converting  some  other  into  a  breech  presentation. 
It  is  of  no  advantage  unless  the  operator  goes  a  step  farther 
and  brings  down  a  foot,  thus  performing  a  podalic  version. 
This  operation,  considered  from  an  elective  stand-point,  and 
not  as  a  measure  of  last  resort,  is  capable  of  producing  more 
favorable  results  than  has  ever  been  credited  to'  it.  It  is  not 
fair  to  charge  this  operation  with  fatal  results  to  mother  or 
child  when  the  operation  has  been  resorted  to  only  after  re- 
peated vain  attempts  to  deliver  the  child  with  forceps,  or  after 
the  mother  has  become  exhausted  with  her  long-continued 
efforts  to  overcome  a  resistance  greater  than  the  force  at  her 
disposal.  In  the  hands  of  one  who  recognizes  the  difficulties  to 
be  overcome,  either  at  the  beginning  of  the  labor  or  soon  after- 
ward, it  becomes  a  powerful  measure  in  saving  lives.  Podalic 
version  is   indicated  (1)  in   transverse  presentations  where  the 


VERSION,  97 

child  is  not  freely  movable,  or  when  cephalic  version  is  not 
indicated ;  (2)  in  head  presentations  where,  from  some  compli- 
cation, the  head  fails  to  engage ;  (3)  in  cases  where  it  becomes 
necessary  to  expedite  the  delivery  while  the  head  is  yet  above 
the  brim  of  the  pelvis ;  (4)  in  head  presentations  where  the 
safety  of  the  mother  or  the  child  is  likely  to  be  endangered 
should  the  head  be  allowed  to  enter  the  pelvic  canal. 

The  indication  for  podalic  rather  than  cephalic  version  in 
transverse  presentations  will  be  found  far  more  frequent,  inas- 
much as  these  cases  are  not  always  diagnosed  in  that  stage  of 
the  labor  which  makes  cephalic  version  possible.  If  the  head  is 
still  above  the  brim  of  the  pelvis  and  movahle^  podalic  version  is 
so  much  less  dangerous  than  delivery  by  forceps  that  it  should 
be  adopted.  Even  in  the  hands  of  the  most  expert  the  applica- 
tion of  high  forceps  is  fraught  with  no  small  danger  to  the 
integrity  of  the  soft  parts  of  the  mother. 

In  that  class  of  cases  where  it  becomes  necessary  to  expe- 
dite the  delivery,  such  as  eclampsia,  placenta  praevia,  accidental 
haemorrhage,  or  pressure  on  the  prolapsed  cord,  podalic  version 
is  the  operation  which  yields  the  very  best  results. 

The  danger  of  allowing  certain  malpositions  of  head  pres- 
entations to  enter  the  pelvic  canal  as  such  is  so  well  known 
and  admitted  that  they  need  but  little  more  than  be  mentioned. 
In  face  presentations  and  in  occipito-posterior  positions  which 
cannot  be  corrected  by  internal  rotation,  podalic  version  should 
be  performed. 

Podalic  version  is  contra-indicated  (1)  when  the  cervix  is 
not  dilated  or  dilatable  ;  (2)  when  the  uterus  is  in  tetanic  spasm 
around  the  fcetus  ;  (3)  when  the  presenting  part  has  become  so 
firmly  wedged  into  the  pelvic  inlet  that  inidue  force  is  neces- 
sary to  push  it  upward ;  (4)  in  contracted  pelves  when  the 
conjugate  is  less  than  three  inches  and  three-quarters,  and  in 
oblique  contractions  when  the  brim  of  the  pelvis  is  seriously 
encroached  upon. 

Operators  who  disregard  the  first  contra-indication  are  the 


98  OBSTETRIC     SURGERY. 

ones  who  will  most  frequently  be  compelled  to  perform  crani- 
otomy on  the  after-coming-  head  wliich  has  been  grasped  in  a 
partially-dilated  cervix.  This,  of  course,  applies  when  extraction 
follows  version  immediately.  The  combined  method  permits 
version  with  but  slight  dilatation  of  the  cervix. 

When  the  uterus  is  in  tetanic  spasm  around  the  foetus  the 
operation  is  fraught  with  so  much  danger  that  it  is  not  ad- 
visable. Long-continued  dry  labors  or  the  injudicious  use  of 
ergot  is  the  most  frequent  cause  of  this  condition,  and  rupture 
of  the  uterus  is  too  possible  an  occurrence. 

If  the  presenting  part  has  become  firmly  impacted  the 
force  necessary  to  dislodge  it  will  endanger  the  integrity  of  the 
soft  parts  so  much  that  the  operation  is  inadvisable,  and  some 
less  dangerous  method  must  be  adopted. 

Although  it  is  easy  to  turn  the  child  in  cases  where  the 
pelvis  is  contracted,  yet  the  delivery  of  a  living  child  is  so  un- 
certain if  the  conjugate  is  less  than  three  inches  and  three- 
quarters  that  it  becomes  a  contra-indication  to  podalic  version. 
Perhaps  one  of  the  most  frequent  causes  of  failure  in  saving  the 
life  of  the  child  in  podalic  version  is  the  neglect  on  the  part  of 
the  operator  to  take  careful  pelvic  measurements. 

It  is  not  meant  tliat  the  physician  must  leave  his  patient 
and  seek  a  pelvimeter  of  some  peculiar  pattern,  but  it  is  meant 
that  with  his  fingers  he  can  form  so  nearly  an  exact  idea  of  the 
true  conjugate  that  he  will  be  able  to  depend  upon  it.  (The 
details  for  doing  this  have  already  been  given  under  the  head 
of  pelvimetry.) 

In  this,  as  in  all  other  obstetric  operations,  it  is  absolutely 
necessary  that  an  exact  diagnosis  should  be  made. 

The  operator  must  have  a  true  mental  picture  of"  the 
position  of  the  foetus  in  utero.  As  stated  under  the  head  of 
ceplmlic  version,  external  palpation  and  vaginal  examination 
will,  in  most  cases,  render  the  diagnosis  clear;  but  it  is  not  in- 
frequent, even  in  the  most  skilled  hands,  to  make  a  mistake  if 
these  two  methods  alone  are  resorted  to.     If  there  is  any  doubt 


VERSION.  99 

it  is  better  to  put  the  patient  thoroughly  under  the  influence  of 
chloroform  and  introduce  the  hand  into  the  vagina  and  two 
fingers  into  the  uterus.  In  head  presentations  the  ear  becomes 
a  most  valuable  landmark.  If  it  is  felt,  it  is  with  perfect  ease 
that  even  one  of  no  great  experience  can  determine  the  position 
of  the  head.  Let  it  be  remembered  that  in  but  very  few  cases 
is  there  necessity  for  haste  in  making  a  careful  examination.  It 
is  only  after  extraction  begins  that  work  must  be  rapid. 

Before  operating,  the  physician  must  have  a  persojia?  knowl- 
edge that  all  the  necessary  preparations  for  the  various  emerg- 
encies which  may  arise  are  at  hand. 

Fluid  extract  of  ergot  and  the  usual  restoratives, — whisky, 
strychnia  tablets,  etc., — together  with  an  hypodermatic  syringe 
in  good  working-order,  should  be  in  readiness.  A  perfectly 
clean,  preferably  new,  gravity  syringe,  with  an  intra-uterine 
glass  nozzle,  should  be  filled  with  some  mild  antiseptic  solution 
Avhich  is  heated  to  118°  F.  (Creolin  solution  1  to  100  and  bi- 
chloride-of-mercury  solution  1  to  10,000  are  as  good  as  any.) 
Basins  of  hot  and  cold  water  and  a  number  of  freshly-laundried 
towels  should  be  in  the  room.  Iodoform  gauze  10  per  cent., 
which  is  known  to  be  fresh  and  clean,  for  intra-uterine  tam- 
ponade, should  be  cut  in  strips  several  yards  long  and  two 
inches  wide.  A  basin  of  some  antiseptic  solution  and  a  new 
nail-brush  should  be  in  easy  reach  of  the  operator.  A  short- 
handled  forceps,  in  case  the  after-coming  head  becomes  arrested 
at  the  brim,  should  be  sterilized.  Needles,  needle-holder, 
silk,  silk-worm-gut  ligatures,  sponge-liolders,  and  artery-clamps 
should  be  boiled  and  placed  in  a  tray  of  sterilized  water.  The 
operator  and  his  assistants  must  be  conscientious  in  the  details 
of  antisepsis.  If  no  operating-gown  is  at  hand,  a  folded  sheet 
can  be  made  to  take  its  place.  The  hands  and  nails  are 
rendered  clean  with  soap  and  brush  and  afterward  by  immer- 
sion in  bichloride-of-mercury  solution  1  to  1000  for  at  least  five 
minutes. 

The  patient  should  be  thoroughly  anaesthetized  and  trans- 


100  OBSTETRIC     SURGERY. 

ferred  from  the  bed  to  any  ordinary  table,  which  has  been 
covered  with  a  blanket  and  a  piece  of  rubber  sheeting.  The 
patient  should  be  placed  on  her  back  and  the  buttocks  drawn 
well  over  the  edge  of  the  table.  Tlie  knees  are  to  be  separated 
and  drawn  up  over  the  abdomen.  Confining  the  knees  in  this 
position  by  means  of  an  improvised  crutch  made  by  tying  one- 
end  of  a  sheet  around  one  of  the  knees,  passing  the  sheet  back 
of  the  patient's  head  and  tying  the  remaining  knee  with  the 
other  end  of  the  sheet  will  leave  more  hands  free  and  necessi- 
tate a  less  number  of  assistants. 

The  vulva  and  adjacent  parts  should  be  thoroughly  cleansed 
with  soap,  water,  and  brush,  and  afterward  with  some  antiseptic 
solution. 

The  catheter  should  be  introduced,  even  though  the  pa- 
tient may  have  recently  passed  her  water.  It  is  wise  for  the 
operator  to  inform  his  assistants  exactly  what  duty  is  to  be  per- 
formed by  each.  It  is  possible  to  perform  this  operation  simply 
with  the  help  of  one  physician  and  a  nurse,  or  some  one  who 
will  act  in  that  capacity  ;  but  it  is  far  better  to  have  the  assist- 
ance of  two  physicians, — one  whose  sole  duty  it  will  be  to  admin- 
ister the  anaesthetic,  and  the  other  to  assist  directly  in  the 
operation.  In  regard  to  the  hand  which  the  operator  should 
use  in  performing  podalic  version,  it  should  be  borne  in  mind 
that  if  an  extremity  is  to  be  grasped  the  palmar  surface  of  the 
hand  must  be  turned  toward  the  abdomen  of  the  child.  If  the 
back  of  the  child  is  to  the  left,  the  left  hand  is  to  be  used;  if  to 
the  right,  the  right  hand  must  be  used.  From  the  variableness 
of  the  position  of  the  child,  the  physician  should  attempt  to 
educate  both  hands  to  an  equal  degree  of  tactile  sensibility. 

As  has  been  stated  previously,  version  may  be  performed 
by  three  methods, — external,  internal,  and  the  combined  exter- 
nal and  internal. 

Pelvic  version  by  the  external  method  is  so  seldom  applic- 
able that  little  need  be  said  of  it.  It  is  not  often  applicable, 
from  the  fact  that  a  substitution  of  a  breech  for  a  head  pres- 


VERSION.  101 

entation  is  scarcely  ever  a  desired  condition.  It  is  not  often 
practical,  inasmuch  as  the  great  majority  of  the  indications  for 
version  presupposes  the  determination  for  rapid  delivery  by 
bringing-  down  a  foot.  In  transverse  presentations  when  the 
waters  have  not  ruptured,  and  when  the  breech  is  nearer  the 
pelvic  brim  than  the  head,  it  may  be  indicated.  While  it  may 
be  in  its  performance  absolutely  without  danger  to  the  mother, 
it  must  be  remembered  that  it  may  put  the  cord  to  such  a  dis- 
advantage that  the  child's  life  will  be  jeopardized. 

If  this  method  is  decided  upon,  the  patient  should  be 
placed  upon  her  back  with  her  knees  drawn  up  so  that  the 
abdominal  walls  may  be  relaxed.  The  operator  stands  to  the 
side  of  and  facing  the  patient.  The  exact  position  of  the  child 
should  be  mapped  out.  The  physician  then  places  one  hand 
over  the  buttocks  and  the  other  over  the  head  of  the  child,  and, 
by  pulling  the  buttocks  toward  him  and  pushing  the  head  up, 
he  attempts  to  convert  the  position  first  into  a  transverse  and 
then  into  a  breech  presentation.  If  the  presentation  is  already 
a  transverse,  and  the  breech  is  nearer  the  brim,  the  head  may  be 
raised  as  the  breech  is  forced  into  the  pelvis.  It  is  necessary 
that  manipulations  be  made  only  during  the  interim  between 
pains,  and  during  the  contractions  of  the  uterus  an  attempt 
should  be  made  only  to  retain  the  amount  of  advantage  gained. 
This  method  presupposes  relaxed  abdominal  walls,  unruptured 
membranes,  and  free  mobility  of  the  child. 

The  combined  method  made  so  famous  by  the  name  of 
Braxton  Hicks,  who  perfected  and  popularized  it,  is  likewise 
limited  in  its  application,  inasmuch  as  it  is  not  often  successful, 
unless  the  liquor  amnii  is  still  present  or  has  only  recently 
escaped,  and  where  considerable  mobility  of  the  child  is  still 
present.  It  is  seldom  performed,  since  version  is  nearly  always 
followed  by  immediate  extraction,  and  this  presupposes  suffi- 
cient dilatation  to  admit  of  the  entire  hand  being  introduced 
into  the  uterus. 

In  certain  cases  of  placenta  praevia  where  hsemorrhage  is 


102  OBSTETRIC     SURGERY. 

taking  place  before  the  cervix  is  very  much  dilated,  the  com- 
bined method  is  of  great  advantage.  In  such  cases  the  prime 
object  is  to  control  the  hsemorrhage,  and  if  the  operator  can 
succeed  in  introducing  even  two  fingers  into  the  uterus  he  may 
be  able  to  draw  down  a  foot  and  thus  plug  the  cervix  with  the 
buttocks.  The  operation  is  not  easy  or  advisable  if  the  head  is 
wedged  in  the  pelvis,  nor  when  the  uterus  is  contracted  around 


Fig.  45.— First  Stage  of  Bipolar  Version. 

the  child.  The  patient  should  be  thoroughly  under  the  influ- 
ence of  the  angesthetic  and  the  buttocks  drawn  over  the  edge 
of  the  table,  as  has  been  described. 

After  thorough  asepsis  on  the  part  of  the  operator  and  his 
assistants  and  the  external  genitals  and  vagina  of  the  patient, 
the  entire  hand,  which  has  previously  been  dipped  into  1  to  100 
creolin  solution,  and  corresponding  to  the  position  of  the  occi- 
put, folded  upon  itself  cone-shape,  should  be  introduced  into 
the  vagina.     All  force  imparted  to  the  hand  should  be  gentle 


VERSION. 


103 


and  at  first  directed  downward  and  backward,  then  forward 
and  upward,  till  the  cervix  is  felt. 

Counter-pressure  with  the  unemployed  hand  can  be  made 
over  the  fundus  of  the  uterus  by  the  operator  better  than  any 
skilled  assistant  can  do  for  him.  This  counter-pressure  answers 
two  purposes :  the  vaginal  attachment  to  the  uterus  is  not  put 
on  an  undue  amount  of  strain  and  the  cervix  is  forced  nearer 
the  examining  finger. 

If  one  finger  only  can  be  introduced,  proceed  to  dilate  with 


Fig.  46.— Grasping  the  Knee. 


the  index  finger,  if  previous  dilatation  has  not  taken  place  (Fig. 
45). 

As  soon  as  two  fingers  can  be  introduced  the  head  is 
sought  and  pushed  up  toward  the  side  to  which  the  occiput  is 
directed,  while  with  the  other  hand  the  buttocks  are  brought 
down  in  the  opposite  direction.  If  extension  of  the  head  has 
taken  place  the  chest  of  the  child  will  be  felt,  which  should  be 
pushed  upward  in  the  same  way  as  in  case  the  head  is  felt.  As 
soon  as  the  head  is  raised  beyond  the  reach  of  the  fingers  the 
knees  are  sought,  which  should  now  be  within  reach.     The 


104  OBSTETRIC     SURGERY. 

knee  must  be  carefully  distinguished  from  the  elbow  before 
traction  is  made  upon  it.  There  will  be  no  difficulty  in  doing 
this  if  the  operator  remembers  that  the  flexed  elbow  points 
toward  the  buttocks  and  the  flexed  knee  points  toward  the 
head.  It  is  not  necessary  to  waste  time  looking  for  the  patella ; 
it  is  difficult  to  recognize,  and  the  above  rule  is  accurate.  If 
the  knee  is  felt,  it  should  be  grasped  (Fig.  46)  between  the  two 


Fig.  47.— Representing  First  Act  of  Extraction. 

fingers  and  brought  still  lower  toward  the  brim  ;  at  the  same 
time  the  other  hand  can  now  be  used  to  push  the  head  toward 
the  fundus.  As  the  knee  is  brought  down  the  fingers  can  be 
made  to  slip  down  the  leg  until  the  foot  is  grasped  and  ex- 
tracted (Fig.  47). 

It  sometimes  happens  that  the  foot  is  felt  before  the  knee  ; 
if  so,  the  position  of  the  great  toe  and  the  malleoli  will  enable 
the  physician  to  distinguish  the  foot  from  the  hand.      If  the 


VERSION.  105 

foot  is  felt  and  recognized  it  should  be  brought  down,  thus 
completing  the  version. 

It  has  already  been  said  that  the  external  method  and  the 
combined  method  of  Braxton  Hicks  are  limited  in  tlieir  appli- 
cations for  the  reasons  stated. 

It  is  the  internal  method  which  has  the  broadest  field  of 
application,  and  which  is  of  incalculable  value  in  certain  cases. 

The  indications  and  contra-indications  have  already  been 
given.  The  position  of  the  patient  and  the  previous  prepara- 
tions are  the  same  as  in  the  external  method.  This  operation 
should  not  be  performed  until  the  cervix  is  fully  dilated  or 
dilatable.  Under  thorough  aseptic  precautions  the  hand  is 
introduced  into  the  vagina  very  gently,  until  the  cervix  is 
reached.  If  the  cervix  is  not  dilated,  its  dilatation  should  be 
at  once  begun.  By  introducing  one  finger  into  the  cervix  it  is 
easy  to  determine  whether  any  constricting  ring  exists  around 
the  OS.  If  such  is  found  to  be  the  case,  and  it  does  not  soon 
yield  to  the  finger,  it  is  wise,  in  case  of  urgency,  to  expedite  the 
dilatation  by  using  the  knife.  Any  blunt-pointed  bistoury, 
which  has  been  protected  by  wrapping  a  piece  of  gauze  around 
the  blade  so  that  only  one-half  inch  at  the  point  is  left  free,  may 
be  used. 

Using  the  fingers  as  a  guide,  the  knife  protected  in  this 
way  may  be  passed  into  the  os  and  six  or  eight  slight  nicks 
made  into  the  hardened  ring  of  the  cervix,  distributed  through- 
out its  circumference.  It  is  not  necessary  that  the  cuts  be  more 
than  an  eighth  of  an  inch  in  depth.  It  will  astonish  one  who 
has  not  tried  this  little  procedure  how  much  this  will  facilitate 
the  dilatation.  Under  gentle  pressure  two,  and  sometimes 
three,  fingers  can  be  introduced  and  the  dilatation  completed. 
If  the  liquor  amnii  has  not  previously  escaped,  care  should  be 
exercised  during  the  dilatation  that  the  fingers  do  not  make 
undue  pressure  on  the  membranes ;  for  it  is  better,  if  possible, 
to  have  the  membranes  intact  until  the  cervix  is  fully  dilated. 
This  procedure  of  manually  dilating  the  cervix,  while  simple,  is 


106 


OBSTETRIC    SURGERY. 


oftentimes  most  trying  on  the  operator's  powers  of  endurance, 
and  frequently  he  will  be  forced  to  delegate  a  part  of  its  per- 
formance to  his  assistant.  The  hand  should  be  redisinfected 
with  creolin  solution  1  to  100,  which  at  the  same  time  takes 
the  place  of  other  lubricants,  whenever  there  is  occasion  to 
introduce  it  into  the  vagina. 

When  the  os  is  fully  dilated  the  operator  should  pass  that 


Fig.  48. — Version  in  Head  Presentation. 


hand  which  corresponds  to  the  position  of  the  occiput  (right 
hand  if  the  occiput  is  turned  to  the  right)  into  the  uterus,  and 
if  the  membranes  are  still  intact  rupture  them.  The  move- 
ments of  the  hand  must  be  gentle  and  hetween  pains.  If  a 
contraction  of  the  uterus  should  take  place,  the  hand  must  be 
flattened  out  and  held  perfectly  still  until  it  has  subsided.  The 
head  is  pushed  to  one  side  and  a  foot  is  sought,  and  as  soon  as 


VERSION. 


107 


it  is  recognized  it  should  be  grasped  (Fig.  48).  Before  traction 
is  made  on  the  foot  it  is  wise  to  note  whether  the  cord  is  looped 
over  the  leg ;  if  so,  it  must  be  released.  While  the  cord  is  be- 
tween the  fingers  its  pulsations  should  be  noted  as  regards  their 
frequency  and  character,  for  this  may  give  the  operator  addi- 
tional reason  for  hastening  the  delivery. 

As  the  foot  is  drawn  down  the  other  hand  is  placed  over 
the  fundus  and  makes  counter-pressure.  It  should  be  the  duty 
of  the  assistant  to  govern  the  movements  of  the  head,  and  as 


Fig.  49. — Completiiifr  tlie  Version. 

soon  as  the  operator  makes  traction  on  the  foot  he  should 
attempt  to  carry  the  head  in  the  opposite  direction. 

As  the  operator  draws  the  foot  down  into  the  vagina,  the 
head  ascends  to  the  fundus  and  the  version  is  completed 
(Fig.  49). 

In  transverse  presentations,  if  there  is  no  prolapse  of  the 
arm,  the  same  method  is  to  be  adopted  for  performing  version 
as  has  been  described  above,  except,  as  the  head  is  already 
above  the  brim,  a  foot  is  sought  at  once. 

In  cases  where  the  arm  has  prolapsed,  but  has  not  become 


108 


OBSTETRIC     SURGERY. 


impacted,  it  can  be  pushed  up  with  but  little  difficulty.  It  is 
well,  however,  while  the  arm  is  still  in  reach,  to  fasten  a  loop 
of  tape  around  the  wrist  before  it  is  pushed  up.  This  will  be 
of  assistance  during  the  extraction,  for,  by  drawing  gently  on 
the  tape,  at  least  that  arm  will  be  prevented  from  becoming 
extended. 

In  those  cases  where  the  arm  has  become  prolapsed  and 
long-continued  uterine  contractions  have  taken  place,  the  thorax 
may  have   become  wedged  into   the  pelvic  outlet.     It  must  be 


Fig.  50.— Impacted  Shoulder. 

borne  in  mind  that  here  it  will  be  necessary  to  replace  that  part 
which  last  came  down  before  the  arm  and  shoulder  can  be  re- 
placed (Fig.  50).  The  thorax  must  be  carried  up  above  the 
brim  before  any  attempt  is  made  to  replace  the  arm.  This  pro- 
cedure requires  the  greatest  care  on  the  part  of  the  physician, 
or  else  a  ruptured  uterus  is  almost  certain  to  result.  If,  after 
making  well-directed  pressure  from  below  with  firm  counter- 
pressure  over  the  fundus,  the  impaction  cannot  be  relieved,  it  is 
better  to  discontinue  the  efforts  to  perform  version,  and  either 
do  embryotomy  in  the  interest  of  the  mother  or,  if  the  mother 


PLATE    YI 


Showing-   Method    of  Grasping  the   Foot. 


VERSION. 


109 


be  in  good  condition  and  the  outlook  for  saving  the  child  not 
too  poor,  resort  to  symphysiotomy. 

The  indications  for  version  almost  always  presuppose 
immediate  delivery. 

Much  has  been  written  on  the  subject,  "  Which  foot  should 
be  drawn  down "?"  If  there  is  no  immediate  reason  for  haste 
and  the  operator  has  time  to  make  his  selection,  it  would  seem 
that  it  is  best  to  draw  down  that  foot  which  is  nearest  the 
anterior  surface  of  uterus.  In  actual  work,  however,  it  does 
not  make  much  difference  which  foot  is  brought  down.     That 


Fig.  51. — Introduction  of  the  Left  Hand  to  Bring  down  the  Posterior  (Left)  Leg. 

one  is  usually  best  which  can  be  soonest  recognized  and  most 
firmly  grasped  (Plate  VI). 

It  is  better,  in  primiparse  certainly,  and  often  in  multiparse, 
that  one  foot  only  be  brought  down,  for  the  cervix  which  has 
permitted  a  half-breech  to  escape  will  be  less  likely  to  grasp 
the  after-coming  head  than  if  it  has  been  dilated  by  the  pelvis 
alone.  If,  however,  traction  on  one  leg  does  not  prove  success- 
ful, it  will  be  necessary  to  draw  down  the  other  (Fig.  51  and 
Plate  VII).  As  the  foot  emerges  from  the  vulva  it  is  to  be 
wrapped  in  a  warm  towel,  which  not  only  offers  a  better  grasp 


no 


OBSTETRIC     SURGERY. 


on  the  part,  but  also  tends  to  prevent  the  cool  air  of  the  room 
from  causing  enough  reflex  irritation  to  establish  respiratory 
efforts  on  the  part  of  the  child.  Soon  the  leg  can  be  grasped  in 
the  same  way,  and  at  this  time  traction  is  to  be  made  in  the 
axis  of  the  brim  downward  (Fig.  52). 

It  is  very  necessary  that  during  the  entire  process  of  ex- 
traction the  assistant  should  make  well-directed  pressure  on  the 
child's  head.     This  tends  to  prevent  extension  of  the  head  and 


Fig.  52. — Showing  Direction  of  Traction. 


also  furnishes  the  vis  a  tergo  ^vhich  the  patient,  by  reason  of 
the  deep  anaesthesia,  cannot  give. 

As  the  buttocks  emerge  from  the  vulva,  one  finger  of  the 
hand  corresponding  to  the  flexed  thigh  should  be  hooked  into 
the  groin ;  this  will  enable  the  operator  to  lessen  the  traction  on 
the  extended  leg,  and  at  the  same  time  permit  him  to  exert 
greater  tractile  force.  By  raising  the  buttocks  and  making- 
traction  upward  the  flexed  thigh  can  be  made  to  clear  the 
vulva.  The  pelvis  should  now  be  grasped  with  both  hands 
and  drawn  downward  again  in  the  axis  of  the  brim. 


VERSION. 


Ill 


As  the  cord  comes  down  it  is  to  be  drawn  upon  from  the 
placental  side,  and  if  it  is  over  one  of  the  legs  it  must  be  re- 
leased (Fig.  53)  and  placed  in  the  most  favorable  position  as 
regards  pressure.  In  rare  instances  it  will  be  impossible  to 
draw  the  cord  down  without  making  undue  traction.  If  such 
should  prove  to  be  the  case,  it  should  be  secured  by  means  of 
two  artery-clamps  and  cut.  Of  course,  if  this  is  done,  it  will 
be  necessary  to  hasten  the  delivery  as  much  as  possible. 

When  the  scapulae  appear  the  arms  must  be  liberated 
before  extraction  is  continued.  Under  favorable  circumstances, 
— that  is,  if  the  assistant  has  kept  up  intelligent  pressure  on 
the  fundus,  or  if  the  cervix  was  fully  dilated  previous  to  the 


Fig.  53.— Method  of  Releasing  the  Cord. 

version,  or  if  the  operator  has  not  made  traction  in  too  rapid 
a  manner, — the  arms  will  be  folded  on  the  chest  and  their  ex- 
traction will  be  eas}^ 

Even  in  the  hands  of  the  best  operators  and  with  the  best 
assistants  the  arms  sometimes  become  unavoidably  extended. 
Although  their  extraction  must  be  accomplished  in  as  rapid  a 
manner  as  possible,  there  is  no  need  of  breaking  the  arm  if  care 
is  taken. 

The  arm  which  is  to  the  rear  is  usually  more  easily  liber- 
ated. To  do  this  the  operator  seizes  the  legs  with  one  hand 
and  carries  the  child's  body  well  upward.  This  will  cause  the 
posterior  shoulder  to  be  more  readily  reached,  and  will  permit 
more  room  for  the   manipulations  necessary.     Two  fingers  of 


112 


OBSTETRIC     SURGERY. 


the  disengaged  hand  are  passed  over  the  back  and  posterior 
shoulder  (Fig.  54).  The  shoulder  can  now  be  pulled  down 
gently  so  that  the  arm  may  be  more  easily  felt.  As  soon  as 
the  humerus  is  felt  it  is  to  be  pushed  forward  and  toward  the 
opposite  shoulder.  Now,  by  drawing  the  humerus  downward 
the  arm  becomes  flexed  at  the  elbow  and  the  forearm  rests  on 
the  chest  of  the  child.  Its  extraction  after  this  is  simple,  and 
the  same  as  in  unextended  cases.  If  it  is  impossible  to  extract 
the  arm  in  this  way,  the  operator  should  pass  the  palmar  surface 
of  his  hand  over  the  abdomen  of  the  child  and  attempt  to  hook 
one  finger  over  the  elbow  of  the  posterior  arm,  and  by  gentle 
traction  flex  it  over  the  chest  (Plate  VIII). 


Fig.  54. — Disengagement  of  the  Posterior  (Right)  Arm. 

After  the  posterior  arm  has  been  liberated,  the  child's  body 
should  be  carried  downward,  and  the  anteriar  arm  is  rarely 
difficult  of  extraction.  Should,  however,  there  be  any  trouble 
in  releasing  it,  the  anterior  shoulder  is  to  be  rotated  to  the  rear, 
where,  with  more  room,  its  extraction  is  simple. 

With  the  arms  released  the  operator  hastens  to  extract  the 
head. 

If  firm  pressure  has  been  maintained  on  the  fundus  the 
head  should  be  found  in  the  pelvis,  either  straight  or  somewhat 
flexed. 

Extraction  of  the  head  may  be  accomplished  either  man- 
ually or  instrumentally.     Inasmuch  as  less  danger  to  both  child 


PLATE    VIII 


Extracting  the    Posterior  Arm. 


VERSION. 


113 


and  mother  results  from  manual  extraction,  forceps  on  the 
after-coming  head  should  be  left  as  a  last  resort. 

If  there  is  no  great  disproportion  between  the  head  and 
the  pelvic  outlet,  extraction  will  not  be  difficult. 

The  child's  body  should  be  wrapped  in  a  warm  towel. 
Grasping  the  pelvis,  with  his  left  hand  placed  underneath  the 
child  and  allowing  the  legs  to  straddle  over  his  arm,  the  operator 
seizes  the  child's  neck  with  his  right  hand,  the  palmar  surface 
of  the  hand  being  over  the  shoulders  of  the  child  and  the  neck 

\ 


Fig.  55. — Showing  Direction  of  Traction. 

between  the  middle  and  third  fingers  (Fig.  55).  Firm  traction 
is  now  made  almost  directly  downward.  When  the  occiput  has 
engaged  immediately  behind  the  pubic  arch,  the  child's  body  is 
to  be  carried  directly  upward  (Fig.  56).  In  favorable  cases,  the 
face,  brow,  and  head  will  sweep  over  the  perineum  and  extraction 
will  be  complete.  So  easy  an  extraction  as  this  is  the  exception, 
however,  from  the  very  fact  that  those  cases  which  demand 
version  usually  presuppose  a  disproportion  between  the  size  of 
the  head  and  of  the  pelvic  canal.     When  such  is  the  case,  other 


lU 


OBSTETRIC     SURGERY. 


manipulations  are  necessary.  The  operator,  as  in  the  precedmg 
method,  lets  the  child's  body  rest  on  his  left  arm.  The  middle 
and  index  fingers  of  the  left  hand  are  passed  into  the  vagina 
until  the  fingers  can  be  applied  on  either  side  of  the  child's 
nose,  the  tips  of  the  fingers  resting  over  the  malar  prominences. 
Traction  is  made  with  this  hand  downward,  while  wdth  the 
right  hand  the  occiput  is  pushed  upward  and  forward.  This 
manipulation  has  the  tendency  to  flex  the  head.  As  soon  as 
flexion  is  accomplished,  the  operator  grasps  the  child's  neck 
with  his  ri»'ht  hand  in   the  manner  described  above,  and  now 


Fig.  56.— The  Child  is  Lifted  Over  the  Perineiim  and  the  Occiput  Passes  from 
Under  the  Symphysis. 


with  both  hands  makes  firm  and  continued  traction.  The  left 
hand  should  remain  over  the  malar  prominences,  and  not  be 
introduced  into  the  child's  mouth,  if  firm  traction  is  to  be  made 
witli  that  hand.  Traction  witli  the  finger  in  the  mouth  does 
not  produce  flexion  to  the  same  degree,  and  if  much  force  is 
used  fracture  of  the  jaw  will  probably  be  produced.  If,  how- 
ever, the  delivery  is  very  difficult  and  prolonged,  if  any  con- 
mlsive  movements  of  the  child  indicate  an  attempt  at  respira- 
tion, or  if  the  pulsations  of  the  cord  are  becoming  imperceptible, 
a  most  valuable  procedure  is  to  introduce  two  fingers  into  the 


h-l 

H 


VERSION. 


11.3 


.  and  oy  siigbtiy  separating  cliem   permit  air  to 

^'s  mouth,  so  that  respiration  may  be  establislied. 

iunst  now   be  depended   upon   to   make  the 

to  complete  the  delivery  (Plate  IX). 

become  arrested  at  the  brim,  extraction  is  iar 

iieie  the  feet  must  be  grasped  with  the  left 

ihe  right  fingers  placed  so  as  to  strnd-':^]e  the  ijore  of 

and   traction  is  to  be  made  direc' 

ne   time   the   assistant  rom  above, 

iug  the  head  d!  u a  mc  head  fail  to 


r'.l  at  SympiiysjR. 

is,  the  operuujr.  lu  ' 


n^  the 


'<ie 


iiid    SilOUici     Uc 

^U/W,  by  making 
enter  tlie  brim  throujili. 
o''t)ie  lesse: 


1  as  u(."scii!)ea  uei<-)rr. 


vnward 


VERSION. 


115 


child's  mouth,  and  by  sHghtly  separating  tliem  permit  air  to 
enter  the  child's  mouth,  so  that  respiration  may  be  established. 
The  right  hand  must  now  be  depended  upon  to  make  the 
necessary  traction  to  complete  the  delivery  (Plate  IX). 

If  the  head  become  arrested  at  the  brim,  extraction  is  far 
more  difficult.  Here  the  feet  must  be  grasped  with  the  left 
hand  and  the  right  fingers  placed  so  as  to  straddle  the  nape  of 
the  neck,  and  traction  is  to  be  made  directly  downw^ard.  At 
the  same  time  the  assistant  makes  firm  pressure  from  above, 
forcing  the  head  downward  (Plate  X).  Should  the  head  fail  to 
descend,  it  will  often  do  so  if  it  is  made  to  enter  the  brim  in  a 


Fig.  57.— Chin  Arrested  at  Symphysis. 

transverse  position.  To  do  this,  the  operator,  in  place  of  making 
traction  while  the  back  of  child  is  directed  upward,  turns  the 
entire  body  of  the  child  so  that  the  back  is  directed  to  the  side 
which  corresponds  with  the  shoulder  that  was  posterior.  (If  the 
left  shoulder  was  posterior,  the  back  of  the  cliild  should  be 
turned  toward  the  left  side  of  the  pelvis.)  Now,  by  making 
traction  directly  downward,  the  head  will  enter  the  brim  through 
its  greatest  diameter  and  descend  into  the  lesser  pelvis.  Trac- 
tion now  will  usually  result  in  the  occiput  turning  forward, 
when  extraction  may  be  completed  as  described  before. 

Should  the  occiput  not  rotate  forward,  then  the  perineum, 
instead  of  the  symphysis,  becomes  the  fulcrum,  and  downward 


116 


OBSTETRIC     SURGERY. 


traction  will  cause  the  face  and  brow  to  sweep  under  the  sym- 
physis and  delivery  is  completed  (Plate  XI). 

In  case,  however,  extension  has  taken  place  and  the  chin 
becomes  arrested  behind  the  symphysis  (Fig.  57),  traction 
should  be  made  upward  and  two  fingers  of  one  hand  should 
be  passed  into  the  rectum  and  the  occiput  "  shelled"  out  over 
the  perineum. 

When  all  these  means  have  been  tried  and  failed,  forceps 
should  be  applied.     The  authors  have  obtained  better  results 


Fig.  58. — Forceps  Applied  to  After-coming  Head. 


with  the  short-handle  Hunter  forceps  than  any  other  used. 
Usually  the  forceps  can  be  adjusted  posteriorly  (Fig.  58  and 
Plate  XII)  better  and  more  quickly  than  anteriorly,  but  it 
should  be  applied  to  that  aspect  of  the  child  which  can  be 
most  rapidly  reached.  It  should  be  applied  to  the  sides  of 
the  pelvis  regardless  of  the  position  of  the  child's  head. 

It  must  be  remembered  that  after  extraction  of  the  arms 
the  head  must  be  delivered  within  three  to  five  minutes  if  a 
living  child  is  to  be  obtained.  It  is  true  that  in  exceptional 
cases  a  living   child  may  be  extracted  wdthin   fifteen   minutes, 


PLATE    XII, 


Application   of  the   Forceps  to  the   After-coming   Head. 


VERSION.  117 

but  this  is  very  rare.  Care  must  be  exercised  that  the  forceps 
does  not  slip  during-  extraction,  or  else  grave  injury  will  result 
to  both  mother  and  child. 

As  has  been  stated  before,  internal  rotation  of  the  foetus  is 
an  operation  which  must  be  included  in  the  consideration  of 
versions,  for  the  operation  consists  in  turning  the  child  hi  its 
long  axis.  This  operation  is  indicated  only  in  occipito-posterior 
positions,  while  the  head  is  yet  movable  above  the  brim.  The 
operation  should  not  be  performed  if  the  head  has  firmly 
engaged,  nor  if  the  waters  have  drained  aw^ay,  nor  if  for  any 
reason  the  labor  must  be  hastily  terminated.  If  the  waters 
have  already  drained  away  and  the  uterus  is  firmly  contracted 
around  the  child,  it  will  be  necessary  to  apply  forceps  and  hope 
for  rotation  in  the  descent.  In  the  great  majority  of  cases  this 
rotation  will  ensue.  If  there  is  any  reason  to  hastily  terminate 
the  labor,  it  is  better  to  perform  podalic  version  and  extract. 
An  occipito-posterior  position  is,  as  a  rule,  associated  with  slow 
engagement,  and  this  is  often  the  first  factor  which  attracts  the 
attention  of  the  obstetrician  to  the  fact  that  the  labor  is  not  a 
normal  one.  The  physician  often  makes  his  first  examination  in 
a  somew^hat  perfunctory  way, — that  is,  he  satisfies  himself  that 
the  head  is  presenting,  and  perhaps  determines  that  the  cervix 
is  slowly  dilating.  If  such  has  been  his  course,  and  if  after 
several  hours  repeated  examination  shows  but  little  increase 
in  the  dilatation  of  the  cervix,  or  that  the  head  does  not  engage 
even  under  the  influence  of  firm  uterine  contractions,  he  should 
at  once  determine  what  conditions  are  present  which  are  pro- 
longing the  first  stage. 

An  examination  w-ith  one  or  two  fingers  introduced  into 
the  vagina,  even  conjoined  wdth  abdominal  palpation,  will  often 
not  result  in  the  information  necessary  to  determine  this  point. 
Certainly  it  will  not  if  the  patient  is  nervous  and  resists  the 
physician's  efi'orts.  An  anaesthetic  should  be  administered  if 
satisfactory  results  are  to  be  obtained  from  the  examination. 

The  preparation  of  the  patient  and  the  operator  should  be 


118  OBSTETRIC     SURGERY. 

the  same  as  for  podalic  version.  The  operator  introduces  that 
hand  into  the  vagina  which  he  is  in  the  habit  of  using  when 
making  a  vaginal  examination.  If  the  cervix  is  dilated  so  that 
two  fingers  can  be  passed  into  the  uterus,  no  further  dilatation 
will  be  necessary  at  this  time.  The  head  should  be  carefully 
raised  between  pains,  and  no  undue  pressure  made  upon  the 
membranes.  The  fontanelles  are  sought  and  examined.  If  any 
doubt  of  the  real  position  remain  after  this,  the  ear  should  be 
felt ;  this  will  be  an  unfailing  guide. 

If  the  occiput  is  posterior  the  cervix  should  be  dilated,  pre- 
paratory to  performing  the  internal  rotation,  in  the  same  way  as 
has  been  described  for  podalic  version.  With  the  cervix  fully 
dilated  the  hand  is  introduced  into  the  uterus.  If  the  head  has 
slightly  engaged,  it  should  be  gently  pushed  up.  The  foetus 
is  now  grasped  and  slowly  rotated  in  its  long  axis  until  the 
occiput  is  anterior.  The  hand  should  now  be  slowly  with- 
drawn until  the  head  can  be  grasped,  and  in  this  position  the 
operator  waits  for  uterine  contraction.  When  this  has  occurred 
the  head  is  driven  down  and  engagement  ensues.  It  is  wise  to 
retain  the  hand  until  two  or  three  contractions  have  taken 
place,  so  that  the  head  may  be  firmly  engaged.  The  case  may 
now  be  left  to  nature,  or,  if  necessity  demands,  the  forceps  may 
be  applied  and  extraction  completed  (Plate  XIII). 

The  course  of  action  herein  advocated  is  not  novel,  nor  is 
it  as  radical  as  at  first  sight  it  may  appear.  The  management 
of  occipito-posterior  positions  has  for  a  long  time  been  a  matter 
of  strife  among  obstetricians.  The  lever,  the  forceps  applied 
inversely,  podalic  version,  the  conversion  into  a  face  presenta- 
tion,— such  means  from  time  to  time  have  been  advocated. 
When  the  occiput,  in  faulty  position,  has  become  impacted, 
certain  of  these  measures  are  forced  upon  us,  with  conse- 
quent damage  to  the  woman  and  with  as  yet  not  sufiiciently 
recognized  injury  to  the  foetal  brain. 

For  the  purpose  of  rotation  nothing  can  take  the  place  of 
the  aseptic  hand,  aside  from  tlie  fict  that  at  one  and   the  same 


PLATE    XITI. 


Method   of  Grasping  the   Child's   Body   in    Performing   Internal    Rotation. 


VERSION.  119 

time  the  hand  may  detect  any  additional  anomaly  hitherto  un- 
suspected, such  as  pelvic  deformity,  which,  aside  from  being  a 
further  cause  of  slow  or  impossible  engagement,  may  alter  the 
field  of  election  at  the  very  best  time  (from  the  stand-point  of 
both  the  woman  and  the  foetus), — that  is  to  say,  when  the  con- 
ditions are  still  favorable  for  version  or  some  other  procedure. 

When  the  occiput  rotates  backward  into  the  hollow  of  the 
sacrum,  we  are  face  to  face  with  what — there  is  uniform  agree- 
ment— constitutes  one  of  the  most  difficult  cases  in  obstetrics. 
Tlie  clean,  educated  obstetric  hand  at  the  pelvic  brim  is  a 
source  of  positive  safety  to  both  the  mother  and  child,  compared 
with  waiting  until  exhaustion  calls  for,  for  instance,  the  forceps 
within  the  pelvic  brim. 

A  tedious  first  stage,  characterized  by  shorty  nagging  pains, 
is  a  fairly-uniform  accompaniment  of  the  instances  which  should 
cause  anxiety.  It  seems  clear  that  manual  examination  at  this 
time  will  often  lead  to  the  adoption  of  a  procedure  which  will 
alter  the  prognosis  of,  and  lessen  the  difficulties  attendant  upon, 
the  persistent  oblique  and  sacro-rotated  occipital  position. 

Prognosis. — Naturally  the  prognosis  will  vary  greatly  ac- 
cording to  the  conditions  demanding  the  operation.  In  those 
cases  where  retraction  of  the  uterus  has  not  taken  place,  and 
where  there  exists  no  disproportion  between  the  head  and  pelvis, 
the  prognosis  for  the  mother  should  be  absolutely  good  if  the 
operation  is  performed  under  aseptic  precautions  and  in  a 
skillful  manner.  The  same  may  be  said  of  the  child  if  the  oper- 
ation is  undertaken  before  the  foetal  heart  shows  signs  of  failure. 
In  tihe  proportion,  however,  that  tliese  favorable  conditions  de- 
crease will  the  mortality  rate  to  the  child  increase.  There 
should  be  no  mortality  at  any  time  for  the  mother  unless  uterine 
retraction  has  taken  place,  the  operation  being  done  only  as  a 
last  resort,  or  where  the  pelvic  outlet  is  markedly  dispropor- 
tionate to  the  foetal  head. 


CHAPTER   V. 
SYMPHYSIOTOMY. 

The  operation  of  symphysiotomy  was  first  performed  in 
the  year  1777  by  Jean  Rene  Sigault.  After  a  protracted  con- 
valescence the  ultimate  result  was  successful,  and  this  led  other 
operators  to  test  the  procedure.  The  results,  however,  were  not 
sufficiently  favorable  to  lead  to  its  general  adoption,  as  shown 
by  the  fact  that  up  to  the  year  1858  the  operation  was  per- 
formed only  86  times,  with  the  loss  of  29  women  and  the  ex- 
traction alive  of  29  children.  The  operation  thence  fell  into 
disuse  until  the  year  1866,  when  it  was  revived  in  Naples  by 
Morrisani  and  Novi.  Outside  of  Italy,  however,  the  operation 
attracted  scarcely  any  attention,  receiving  but  scant,  if  any,  ref- 
erence in  works  on  obstetrics  until  the  year  1890,  when,  largely 
through  the  publications  of  Pinard,  of  Paris,  and  Harris,  of 
Philadelphia,  the  attention  of  obstetricians  was  attracted  to  the 
really  beneficent  results  which  were  being  secured  through 
timely  resort  to  it.  The  unfavorable  residts  from  the  operation 
during  its  early  years  were  unquestionably  clue  to  the  lack  of 
appreciation  of  the  necessity  of  both  asepsis  and  of  election, 
and  therefore  our  study  of  the  operation  need  be  based  purely 
on  the  results  which  are  yielded  in  modern  times,  when  both 
of  these  factors  play  the  chief  role  in  obstetric  surgery. 

In  1892  Harris  collated  the  operations  which  had  been 
performed  from  January,  1886,  up  to  July,  1892,  as  follows: 
44  operations,  with  one  maternal  death  and  the  loss  of  4  chil- 
dren. Up  to  this  time  the  operation  had  never  been  performed 
in  the  Unitc^d  States,  although  practical  obstetricians  had  been 
giving  much  attention  to  another  alternate  operation  having  in 
view  the  avoidance  of  embryotomy, — the  Csesarean  section. 
From  this  date  on,  however,  as  if  by  magic,  operations  were 
reported  from  various  sections  of  the  country  until  we  are  now 
(120) 


SYMPHYSIOTOMY.  121 

in  the  position  of  being  able  to  judge  the  operation  from  the 
stand-point  ot"  liome  results.  Meanwhile,  Pinard,  in  Paris,  has 
been  equally  active,  and  the  number  of  recorded  operations  has 
reached  a  sufficiently  large  basis  to  admit  even  of  a  degree  of 
dogmatism  in  tlie  estimation  of  the  proper  sphere  of  symphysi- 
otomy. The  inevitable  result  of  the  rapid  acceptance  of  the 
operation  has  been,  as  will  be  noted,  a  higher  mortality  rate, — 
in  a  measure  doubtless  due  to  the  inexpertness  of  the  majority 
of  operators  performing  their  first  of  the  kind. 

Indications  and  Limitations. — The  aim  of  the  operation  of 
symphysiotomy  is,  through  section  of  the  pubic  joint,  to  allow 
of  separation  of  the  symphysis,  whereby  the  pelvic  diameters  are 
widened  sufficiently  to  enable  the  delivery,  j9e?-  vias  naturales, 
of  a  foetus  which  otherwise  would  have  to  be  sacrificed.  The 
operation,  then,  is  performed  purely  in  the  interests  of  the 
child,  takiug  the  place  of  embryotomy  and  displacing  the 
Caesarean  section  from  the  stand-point  of  the  relative  indications. 
Before  the  resuscitation  of  symphysiotomy,  indeed,  the  alterna- 
tive was  either  mutilation  of  the  foetus  or  the  subjection  of  the 
woman  to  the  major  operation  of  abdominal  section.  When, 
therefore,  symphysiotomy  becomes,  as  it  should,  an  elective 
operation,  with  consequent  lowering  of  the  maternal  mortality 
rate  to  nil.,  there  will  exist,  other  things  equal,  no  further  call 
for  embryotomy,  and  the  Csesarean  section  will  be  reserved 
strictly  for  cases  which  fall  under  the  absolute  indication.  It  is 
significant,  indeed,  that  more  than  one  obstetrician  in  Europe 
is  already  on  record  as  claiming  that  the  time  has  definitely 
arrived  when  the  physician  is  not  called  upon  to  sacrifice  the 
living  foetus.  In  the  United  States,  however,  the  time  is  not 
ripe  for  snch  an  extreme  statement  outside  of  maternity  hos- 
pitals. In  private  practice  the  woman  lierself  or  her  representa- 
tive must  continue  to  exercise  the  rio^ht  of  choice  until  the 
mortality  rate  from  symphysiotomy  has  fallen  to  a  figure  at 
least  as  low  as  in  expert  hands  is  associated  with  embryotomy. 

Through  experiment  on  the  cadaver  we  have  learned  that 


122  OBSTETRIC     SURGERY. 

when  the  pubic  symphysis  is  cut  and  the  knees  of  the  cadaver 
are  separated  the  pubic  bones  diverge,  without  inflicting  damage 
on  the  sacro-iliac  joints,  to  the  extent  of  two  and  three-fourths 
to  three  inches.  Into  the  opening  formed  in  iront  the  present- 
ing part  of  the  foetus  may  enter  and  the  following  space  is 
gained  in  the  various  diameters  of  the  pelvis.  The  true  conju- 
gate increases  to  the  extent  of  from  one-fourth  to  one-half  an 
inch  and  the  transverse  and  oblique  diameters  gain  from  three- 
fourths  to  one  and  a  half  inches.  It  is  at  once  apparent  how, 
with  a  foetus  of  average  size,  this  operation  enables  delivery  to 
be  accomplished  without  mutilation  of  the  foetus,  since  the  gain 
in  the  pelvic  dimensions  applies  with  equal  force  to  the  types 
of  deformed  pelves  most  frequently  met  with, — the  flat  and  the 
generally  contracted. 

The  indications  for  the  operation  are  as  follow :  The  con- 
sent of  the  woman  or  her  representative.  The  foetus  viable  and 
the  woman  and  the  foetus  not  exhausted  through  protracted- 
labor.  Careful  precedent  pelvimetry,  instrumental  and  manual, 
proving  that  there  exists  dystocia  which  will  not  yield  to  either 
version  or  the  forceps  and  testifying  to  the  existence  of  a  type 
of  pelvis  where,  after  pubic  section,  the  sacro-iliac  syncliondroses 
will  yield.  In  the  generally  contracted  pelvis  the  conjugata 
vera  must  be  at  least  three  and  three-fourths  inches  in  dimen- 
sions, and  in  the  flat  pelvis,  where  it  will  be  borne  in  mind  the 
transverse  diameter  is  relatively  wdde,  the  conjugata  vera  maybe 
reduced  even  to  two  and  three-fourths  inches  if  the'  child  is  below 
the  average  size.  In  impacted  occipito-posterior  positions  and 
in  irreducible  face  presentations.  The  cervix  must  be  dilated 
or  dilatable.  The  presence  of  ankylosis  of  one  or  the  other 
sacro-iliac  joint  must  be  ruled  out. 

Before  passing  to  a  consideration  of  the  technique  of  the 
operation,  it  is  well  to  recall  briefly  the  st-ructures  involved  in 
the  operation  and  to  point  out  the  risks  to  which  the  maternal 
structures  are  subjected.  In  the  vast  majority  of  women  at  or 
near  term  there  exists  normally  a  certain  amount  of  separation 


SYMPHYSIOTOMY.  123 

at  the  symphysis,  provided  this  be  not  ankylosed,  when,  of 
course,  the  operation  is  per  se  contra-indicated.  The  operation 
is  entirely  extra-peritoneal,  the  bladder  stripped  of  the  perito- 
neum, and  the  urethra  lying  immediately  under  the  symphysis. 
In  certain  instances,  however,  as  Dickinson,  of  Brooklyn,  re- 
minds us,  the  peritoneum  pouches  downward,  and  there  may  be 
danger  of  injuring  this. 

As  a  rule,  however,  the  bladder  and  the  urethra  are  the 
only  organs  which  are  hkely  to  be  injured,  and  these,  we  will 
show,  need  not  be  if  the  requisite  care  is  taken  during  the  per- 
formance of  the  operation  and  afterward  when  the  parts  are 
brought  together.     We   are   speaking  now,   of  course,   of  the 


Fig.  59.— The  Bulging  of  Peritoneum  and  of  Bladder  into  the 
Opening  at  the  Joint 

subcutaneous  performance  of  the  operation,  the  metliod  Avhich 
is  favored  by  most  practical  accoucheurs.  The  open  method  of 
operating  involves  the  structures  and  the  vessels  which  cover 
tlie  anterior  face  of  the  pubes,  and  the  selection  of  this  method 
of  operating  converts  symphysiotomy  into  a  much  more  serious 
operation  and  complicates  greatly  convalescence  as  well. 

The  two  factors  which  control  the  result  of  this  opei'ation 
are  election  and  asepimkm  Where  the  operation  is  indicated 
it  should  be  performed  in  a  timely  manner,  and  to-day  there  is 
no  excuse  for  inattention  to  the  stringent  rules  of  cleanliness 
whereby  the  surgery  of  the  present  is  so  sharply  differentiated 
from  tliat  of  the  past.  If  but  one  lesson  has  been  taught  by 
the  results  secured  during  the  past  three  years,  it  is  that  sym- 


124  OBSTETRIC     SURGERY. 

physiotomv  need  not  have  a  mortality  rate.  As  will  be  noted 
later,  the  fatal  cases  resulting  since  the  rejuvenation  of  the 
operation  have  been  due  either  to  the  fact  that  the  operation 
has  been  performed  on  an  exhausted  woman,  or  else  because, 
through  inattention  to  asepsis,  the  woman  has  succumbed  to 
septicaemia. 

The  instruments  essential  for  the  performance  of  the  opera- 
tion are:  a  stout,  blunt-pointed  bistoury,  a  few  artery-forceps,  a 
needle-holder,  needles,  a  metallic  catheter,  or  a  metal  sound. 
Silk-worm  gut  forms  the  preferable  material  for  sutures.  The 
Galbiati  knife,  which  is  highly  favored  by  the  Italians,  has  been 
found  unnecessary.  Indeed,  in  certam  cases,  the  use  of  this  m- 
strument  is  dangerous  to  the  integrity  of  the  maternal  parts,  if 
resort  to  it  be  at  all  possible. 


Fig.  60.— Galbiati-Harris  Knife.     (Harris's  Modification.) 

In  certain  exceptional  instances  the  symphysis  of  tlie  pubes 
deviates  from  the  mid-line,  and  in  others  the  union  of  the  halves 
is  not  cartilaginous,  but  bony.  When  this  untoward  complica- 
tion is  present  it  will  be  impossible  to  separate  the  symphysis 
w^ith  a  knife,  and  a  chain-saw  is  requisite.  Fortunately,  this 
occurrence  is  a  rarity;  still,  the  physician  should  be  prepared  for 
every  emergency,  and,  therefore,  should  add  a  saw  to  his  arma- 
mentarium. 

Teclinique  of  the  Operation. — The  method  of  operating 
which,  is  favored  by  the  vast  majority  of  those  who  have  had 
practical  experience  is  the  subcutaneous  one.  There  are 
weighty  reasons  why  the  open  method  should  be  rejected.  If 
this  is  selected   it  will  be  very  difficult  to  avoid  infecting  the 


SYMPHYSIOTOMY.  125 

wound  with  lochia  during  convalescence,  and,  further,  the 
tissues  near  the  clitoris  are  peculiarly  vascular, — all  the  more 
so  during  pregnancy, — and  section  made  in  this  neighborhood 
exposes  the  woman  to  the  risk  of  considerable  hajmorrhage  of 
a  type  very  difficult  to  control.  There  are  a  sufficient  number 
of  modern  instances  of  tlie  operation  on  record  now,  where  the 
subcutaneous  method  was  followed,  to  prove  its  perfect  feasi- 
bility, and  in  certain  cases  its  wonderful  simplicity.  Although 
trained  assistants  are  helpful,  their  presence  is  not  strictly 
requisite. 

The  woman  having  been  anaesthetized,  the  abdomen  is  pre- 
pared as  for  an  abdominal  section, — that  is  to  say,  the  pubes 
are  carefully  shaved  and  thoroughly  disinfected.  The  bladder 
is  emptied.  An  incision  is  made  in  the  mid-line  down  to  the 
recti  muscles,  beginning  at  the  suprapubic  eminence,  and  ex- 
tending upward  for  about  three  inches.  The  recti  are  separated 
by  the  finger  and  the  handle  of  the  scalpel,  and  this  brings  us 
to  the  retropubic  space.  A  catheter  is  now  inserted  into  the 
bladder  and  handed  to  an  assistant  to  depress  the  urethra  from 
under  the  pubes.  This  is  a  highly  important  step,  since  one  of 
the  accidents  associated  with  the  performance  of  symphysiotomy 
is  injury  to  the  neck  of  the  bladder.  Tlie  accident  is  entirely 
avoidable,  and  much  depends,  therefore,  on  the  assistant  who 
holds  this  catlieter.  The  operator's  index  finger  is  next  in- 
serted under  the  symphysis  to  further  protect  the  bladder,  and 
it  must  be  held  there  until  the  section  of  the  pubic  symphysis  is 
completed.  If  the  fcetal  presenting  part  has  not  as  yet  engaged, 
or,  in  case  it  has,  if  the  part  can  be  pressed  upward,  the 
inserting  of  the  finger  is  easy,  and  there  remains  further  space 
for  the  Galbiati  knife  if  the  operator  prefer  it;  but  in  case  of 
engagement  of  the  foetal  part  it  will  be  found  difficult  to  insert 
the  finger,  and,  tliis  accomplished,  there  is  scant  room,  if  any, 
for  the  sickle-shaped  knife,  Hence  the  reason  why  later  opera- 
tors have  discarded  this  knife  and  substituted  the  stout,  blunt- 
pointed  bistoury.     The  finger  being  in  place  below  the   sym- 


fi^ 


126  OBSTETRIC     SURGERY. 

pliysis,  the  union  of  the  pubic  bones  is  incised  in  the  direction 
from  above  downward  and  from  wifciiaut  iiiward.  The  operator 
must  not  be  satisfied  until  he  has  severed  the  inferior  hgament 
of  the  pubes.  If  he  fail  to  accomplish  this  the  pubic  bones 
simply  separate  at  the  top,  and  there  is  scant  gain,  if  any,  in  the 
pelvic  diameters.  As  soon  as  the  subpubic  ligament  has  been 
severed',  the  pubic  bones  separate  and  the  pelvis  becomes  en- 
larged. As  already  noted,  a  separation  of  from  two  and  one- 
half  to  three  inches  is  possible  without  inflicting  damage  on  the 
sacro-iliac  synchondroses.  In  order  to  avoid  separation  beyond 
this,  an  assistant  on  either  side  of  the  woman  should  make  firm 
inward  pressure  on  the  trochanters  whilst  delivery  is  being 
effected. 

Any  hsemorrhage  occurring  during  the  steps  of  the  opera- 
tion should,  if  arterial,  be  checked  by  torsion  or  ligature. 
Venous  oozing,  wdiich  is  apt  to  be  considerable,  is  met  by  the 
tampon  with  sterilized  gauze.  This  tampon  is  left  in  place 
until  delivery  has  been  effected. 

It  has  been  claimed  that  after  division  of  the  symphysis 
delivery  should  be  left  to  nature,  except  in  instances  wdiere  the 
condition  of  the  woman  or  the  foetus  requires  hasty  action. 
There  is,  however,  no  advantage  in  this.  The  cervix  being 
dilated  or  dilatable,  since  the  woman  is  under  anaesthesia,  there 
is  nothing  to  be  gained  by  delay.  If  the  head  is  above  the 
brim,  the  membranes  unruptured,  or  if  the  presenting  part  has 
iust  ena:ao-ed  and  the  membranes  are  intact,  the  conditions 
favorable  for  version  are  present  and  there  is  no  valid  reason 
why  the  physician  should  not  proceed  to  deliver  after  tliis 
fashion.  The  chances  are  that  the  operation  of  symphysiotomy 
has  been  called  for  on  account  of  maternal  or  of  foetal  dystocia, 
and  under  such  condition,  where  version  is  possible,  it  should 
always  be  elected  over  the  forceps.  Where  the  presenting  part 
has  engaged,  but  cannot  be  delivered  short  of  symphysiotomy, 
owing  to  contraction  at  the  outlet,  the  forceps  should  be  applied 
lege  artis.     If  the  operation  of  symphysiotomy  has  been  elected 


SYMPHYSIOTOMY.  127 

to  enable  the  delivery  alive  of  a  foetus  presenting  in  a  mento- 
posterior or  in  an  occipito-posterior  impacted  position,  then, 
after  symphysiotomy,  the  malposition  should  be  corrected  as 
far  as  is  feasible,  and  delivery  be  effected  by  the  forceps. 

After  completion  of  the  third  stage  of  labor,  the  operator 
should  turn  his  attention  at  once  to  the  repair  of  the  wound 
made  necessary  by  the  symphysiotomy.  The  aseptic  catheter  is 
agahi  introduced  into  the  bladder  and  handed  to  an  assistant  in 
order  that  the  urethra  and  the  bladder  may  be  pressed  down- 
ward carefully  whilst  the  pubic  bones,  are  being  brought  into 
apposition.  This  step  is  a  most  important  one.  If  neglected, 
or  if  carelessly  performed,  the  bladder  or  urethra  will  be 
nipped  in  the  symphysis,  and  in  the  course  of  a  few  days  a 
fistula  will  be  established.  The  thighs  of  the  woman  are  ro- 
tated inward,  and  firm  pressure  is  made  on  the  trochanters  by 
two  assistants.  The  pubic  bones  are  thus  brought  together, 
and  are  held  there  until  the  wound  in  the  abdomen  has  been 
properly  sutured  and  the  bandage  has  been  applied.  If  tlie 
subcutaneous  operation  has  been  performed,  as  we  believe  it 
should,  it  is  useless  to  attempt  to  suture  the  symphysis.  Nor 
is  this  necessary.  Where  the  operation  has  been  performed 
aseptically,  and  a  proper  bandage  is  applied,  the  pubic  bones 
will  remain  in  apposition  and  unite  firmly.  Unless  the  woman 
is  specially  fat,  deep  silk-worm-gut  sutures  Avill  suffice  for  bring- 
ing together  the  abdominal  wall.  If  the  woman  is  stout  it  is 
preferable  to  unite  the  divided  recti  muscle  by  a  running  catgut 
suture  and  to  treat  the  skin  and  fat  by  the  open  method,  which 
insures,  in  such  cases,  firmer  union,  After  the  sutures  are  in 
position  and  the  usual  dressing  has  been  applied,  a  wide  strip 
of  adhesive  plaster,  extending  from  the  trochanters  nearly  to  tlie 
umbilicus,  is  carried  around  the  woman,  whilst  the  assistants  are 
maintaining  firm  pressure  on  the  trochanters.  This  immobil- 
izes the  pelvis  efficiently,  and,  barring  indication  of  suppuration 
in  the  wound,  this  dressing  need  not  be  changed  for  from  five 
to  ten  days.     The  after-treatment  of  the  case  is  exactlv  similar 


128  OBSTETRIC     SURGERY. 

to  that  which  holds  for  the  normal  puerperium,  except  that 
very  likely  it  will  be  necessary  to  catheterize  the  woman.  The 
woman  should  be  kept  on  her  back  for  the  first  week,  but  after 
this  period  she  may  lie  on  her  side.  She  should  be  kept  in  bed 
for  at  least  three  weeks,  although  cases  have  been  allowed  to 
rise  sooner  with  apparently  no  bad  effect.  As  a  rule,  in  every 
woman,  after  symphysiotomy  there  will  exist,  for  a  variable  in- 
terval, a  greater  or  less  degree  of  motion  at  the  joint,  but  we 
question  if  this  is  greater  than  that  which  normally  exists  in 
young  primiparae  after  a  difficult  non-instrumental  labor.  The 
fact  seems  to  have  been  overlooked  that  in  probably  the  ma- 
jority of  gravid  women  there  exists  motion  at  the  symphysis  for 
a  variable  interval.  This  motion,  however,  is  not  associated 
with  disability,  and  before  very  long  the  fibrous  tissue  becomes 
oro-anized  and  motion  cannot  be  detected.  Even  if  there  should 
remain  a  degree  of  separation  at  the  symphysis  after  symphysi- 
otomy, we  should  not  look  upon  this  as  an  evil,  for  in  the 
event  of  a  future  pregnancy  a  second  operation  might  not  be 
demanded  should  the  woman  be  allowed  to  go  to  term. 

Complications. — In  the  reported  modern  cases,  the  only 
ones  which  need  concern  us,  the  most  unfortunate  complication 
noted  has  been  the  formation  of  a  fistula  of  tlie  urinary  tract, 
either  vaginal  or  abdominal.  The  essential  step  for  avoiding 
this  we  have  already  laid  stress  upon.  If,  notwithstanding,  the 
accident  should  occur,  often  the  lesion  will  heal  spontaneously 
under  cleanliness  and  catheterization.  If  spontaneous  repair 
should  not  occur,  then,  some  time  after  the  puerperium,  a  sec- 
ondary operation  will  be  called  for.  It  is  a  noteworthy  fact  that 
fistulse  have  chiefly  occurred  in  instances  where  the  operation 
has  been  resorted  to  only  after  tlie  foetal  presenting  part  had  be- 
come wedged  in  the  pelvic  brim,  and  where  the  Galbiati  knife 
had  been  used.  AVe  believe  that  when  it  becomes  the  practice 
to  elect  the  operation  before  engagement,  or,  at  any  rate,  before 
futile  attempts  at  engagement  have  necessarily  resulted  in  more 
or   less  pressure  on  the  neck  of  the  bladder,  this   complica- 


SYMPHYSIOTOMY.  129 

tion  will  become  excessively  infrequent.  Further,  we  question 
if  the  use  of  the  Galbiati  knife,  in  cases  where  the  presenting 
part  has  engaged,  is  not  responsible  for  many  of  the  fistulae. 
As  we  have  already  stated,  when  the  presenting  part  has  en- 
gaged there  is  scant  room  for  the  insertion  of  both  the  finger 
and  the  knife  under  the  symphysis.  The  insertion  of  the  finger 
is  absolutely  necessary  in  order  to  insure  the  safety  of  the 
bladder ;  the  Galbiati  knife  is  not  necessary  for  the  performance 
of  the  operation.  The  majority  of  operations  in  this  country 
have  been  performed  without  this  knife,  and  we  would,  there- 
fore, limit  its  utility  to  instances  where  the  foetal  presenting  part 
has  not  engaged,  and  where,  therefore,  there  is  ample  room  both 
for  the  linger  and  the  knife. 

Haemorrhage  as  a  complication  of  the  operation  need  not 
be  feared  where  the  subcutaneous  method  is  selected.  At  best 
this  is  only  venous  oozing,  which  is  easily  controlled  by  the 
gauze  tampon.  The  open  method  of  operating,  which  we  do 
not  indorse,  entails,  of  course,  wounding  of  the  ^•enous  plexuses 
of  the  vestibule,  as  also  the  vessels  which  nourish  the  clitoris. 
Hsemorrhage  from  this  source  may  be  very  difficult  to  control, 
and  the  essential  manipulations  required  carry  extra  chance  of 
septicizing  the  woman.  The  open  method  of  operating,  then, 
should  be  strictly  reserved  for  instances  where  deviation  of  the 
symphysis  from  the  mid-line,  or  where  the  bony  ankylosis 
forbids  the  performance  of  the  operation  by  means  of  the  knife, 
and  calls  for  the  chain-saw. 

The  further  complication  which  is  responsible  for  the  loss 
of  a  fair  percentage  is  septic  infection, — a  complication  common 
to  every  surgical  procedure,  and  an  avoidable  one. 

When  the  operation  was  resuscitated  it  was  feared  that  the 
ultimate  result  as  regards  locomotion  would  be  bad.  The 
record  of  the  miodern  cases  certifies,  however,  tliat  this  fear  is 
unfounded.  In  many  of  the  women  there  exists  for  a  variable 
period  a  certain  amount  of  motion  at  the  joint,  and  in  some 
cases  the  women  complain  of  a  sensation  of  motion  there ;  but 


130  OBSTETRIC     SURGERY. 

before  long-  tlie  fibrous  tissue  becomes  organized,  and  these 
physical  and  rational  symptoms  disappear. 

Prognosis. — For  tlie  purpose  of  determining  statistically 
the  prognosis  of  this  operation,  we  shall  consider  alone  the  data 
which  have  accrued  during  the  past  few  years.  Prior  to  this 
period  careless  asepsis  was  responsible  for  a  very  high  mortality 
rate. 

The  following  data  will  enable  us  to  judge  the  prognosis 
fairly :  In  general  the  mortality  rate  has  varied  from  8  to  12  per 
cent.  In  the  United  States  31  operations  have  been  performed 
up  to  March,  1894,  with  •!  deaths.  Analyzing  these  cases,  we 
find  that  in  not  a  single  one  of  these  fatal  cases  was  the  opera- 
tion elective.  Thus:  The  first  fatal  case  had  been  in  labor 
twenty-five  hours,  and  was  exhausted,  with  a  pulse  of  150,  when 
operated  upon  ;  the  second  case  died  of  septic  peritonitis ;  the 
third  died  of  pneumonia ;  the  fourth  had  been  in  labor  three 
days,  and  died  on  the  eleventh  day,  of  sepsis  originating  in  the 
subosseous  wound. 

Of  the  last  15  operations  in  the  United  States  there  has 
been  1  death. 

In  1893,  Pinard,  of  Paris,  performed  the  operation  13 
times.  He  has  had  1  maternal  death.  She  died  of  sepsis,  having 
been  operated  upon  after  she  had  been  in  labor  three  days. 
The  sepsis  might  have  originated  before  she  entered  the  hos- 
pital. Of  this  last  series  all  the  children  have  been  saved.  In 
the  last  31  operations  in  the  United  States  there  were  9  foetal 
deaths.  Eio-ht  of  these  cliildren  would  have  been  saved  had 
the  operation  been  elective. 

From  a  critical  examination  of  these  recent  data,  it  is  ap- 
parent that  the  operation  of  symphysiotomy  need  not  have  a 
mortality  rate  when  it  is  an  elective  operation.  The  sole  risk 
the  woman  runs  is  from  sepsis, — a  risk  which  is  associated  with 
every  operation,  both  major  and  minor.  Here,  again,  the 
beneficent  doctrine  of  election  comes  into  the  foreground  in. 
operative  obstetrics. 


SYMPHYSIOTOMY.  131 

However  bright  the  prospects  of  the  operation  are  for  the 
future,  it  still  remains  true  that  for  the  present  it  will  find  its 
chief  field  in  maternity  hospitals.  We  feel  that  as  yet  a  suffi- 
cient number  of  cases  are  not  on  record  to  warrant  the  phy- 
sician in  stating  that  there  are  no  untoward  results  as  regards 
locomotion.  In  private  practice,  therefore,  it  is  essential,  in 
order  to  guard  against  a  possible  suit  for  malpractice,  to  be 
very  guarded  in  regard  to  the  ultimate  prognosis  in  this  re- 
spect. Our  own  feeling  in  the  matter  is,  that  the  future  will 
establish  this  operation  on  the  firm  ground  of  a  scientific  one, 
and  when  that  day  arrives  there  will  exist  no  further  warrant 
for  the  performance  of  embryotomy  on  the  living  in  case  of  the 
lesser  grades  of  pelvic  deformity. 


CHAPTER   VI. 
CJESAREAX   SECTION. 

If  the  foetus  is  removed  from  the  mother  by  means  of  an 
incisiou  through  the  abdominal  and  uterine  walls,  the  operation 
is  kno^vn  as  Ceesarean  section.  The  reader  is  referred  to  the 
numerous  monographs  which  have  been  written  on  this  subject 
for  its  history  and  the  various  modifications  through  which  it 
has  passed. 

Perhaps  of  no  other  operation  can  it  be  said  that  the 
application  of  the  iiiles  of  modern  aseptic  surgery  has  accom- 
pHshed  so  much  as  in  the  one  under  consideration.  It  will 
require  time  yet,  however,  before  the  old  prejudice  among  phy- 
sicians and  laity,  engendered  by  reason  of  the  unnecessary 
large  mortality  which  accompanied  this  operation,  can  be 
eradicated.  Statistics  which  embrace  operations  performed  ten 
or  even  five  years  ago  are  of  but  little  value,  inasmuch  as  the 
teclmique  of  the  operation  has  been  so  modified  and  perfected 
that  results  are  entkely  different. 

The  operation  now  is  no  longer  postponed  until  the 
mother's  vital  forces  have  been  spent  in  unsuccessful  attempts, 
either  on  her  part  or  on  the  part  of  the  obstetrician,  in  deliver- 
ing the  fcetus  per  vio.s  naturales. 

ladlcations. — Cassarean  section  may  be  performed  either 
from  absolute  or  relative  indications.  If  the  pelvic  contraction 
is  so  marked  that  delivery  of  the  child  by  the  natural  passages 
be  impossible,  or  if  the  pelvic  canal  be  obstructed  by  solid,  be- 
nign, or  mahgnant  growths,  the  operation  is  absolutely  indicated. 

Csesarean  section  should  be  performed  if  the  mother  is 
moribund  or  has  just  died,  if  tlie  cliild  is  still  alive. 

The  relative  indication  has  a  much  wider  scope,  and  what 
is  advocated  here  in  this  regard  would  not  have  been  admissible 
a  few  years  ago,  when  the  mortality  rate  was  so  high.  How- 
'(132) 


CESAREAN     SECTION.  133 

ever,  in  the  light  of  recent  cases,  and  when  it  is  remembered 
how  great  a  mortahty  exists  as  a  result  of  embryotomy,  and 
how  repulsive  it  is  to  every  physician  to  deliberately  destroy  a 
life,  it  is  certainly  clear  that  Csesareau  section  of  the  future  will 
be  done  more  frequently  for  relative  indications  and  as  an 
elective  operation. 

Given  an  instance  of  pelvic  contraction  in  which  the 
chances  are  against  the  delivery  of  a  living  child  per  vias 
naturales,  and  the  time  for  induction  of  premature  labor  with 
resulting  liable  child  having  elapsed,  the  obstetrician  is  justi- 
fied in  performing  the  Csesarean  section,  provided  always  the 
foetal  heart-sounds  are  clear  and  regular.  The  operation  is  not 
only  done  here  for  relative  indications,  but  is  an  elective  one 
rather  than  as  a  last  resort,  as  has  too  often  been  the  case.  The 
patient  is  carefully  prepared  for  it  previous  to  or  at  the  begin- 
ning of  labor,  and,  before  she  has  had  a  chance  to  become  in 
the  least  exhausted  either  by  nature  or  by  art.  the  abdomen  is 
opened  and  the  child  delivered.  When  the  operation  is  con- 
sidered from  this  point,  embryotomy  of  tlie  livino-  foetus  will 
become  a  lost  art. 

Operation. — Perhaps  there  is  no  operation  the  success  of 
which  depends  so  largely  on  the  many  and  various  little  details 
as  in  CEesarean  section.  The  operator  must  have  a  personal  ob- 
servation of  the  preparation  for  the  operation,  if  the  best  results 
are  to  be  obtained.  Formerly  it  was  thought  best  to  wait  for  the 
woman  to  go  into  labor  before  the  operation  was  begun;  but  in 
those  cases  where  it  ])as  been  predetermined  that  the  operation 
is  necessary,  it  is  far  better  to  elect  the  time  of  its  performance. 
The  old  idea  that  a  certain  amount  of  previous  cervical  dila- 
tation was  necessary  no  longer  holds  good,  in  the  light  of  the 
fact  that  a  few  moments  only  are  necessary  to  sufficiently  dilate 
the  cervix.  The  advantage  which  is  to  be  gained  by  the  delib- 
erate preparation  of  the  patient,  to  say  nothing  of  being  able  to 
select  the  hour  and  light  for  the  operation,  more  than  compen- 
sates for  the  dilatation  of  the  cervix  which  the  normal  labor- 


134  OBSTETRIC     SURGERY. 

pains  would  induce.  The  statement  that  the  uterus  will  contract 
more  firmly  if  labor  has  already  begun  is  purely  theoretical,  for, 
in  point  of  fact,  experience  with  just  such  cases  has  proven 
that  the  uterus  does  contract  firmly  as  soon  as  it  is  emptied. 

The  operation  is  much  more  easily  performed  if  a  sufficient 
number  of  well-trained  assistants  are  at  hand.  It  is  wise,  how- 
ever, that  as  few  hands  as  possible  be  introduced  into  the  peri- 
toneal cavity,  for,  in  this  way,  the  possibilities  of  infection  are 
lessened.  There  should  be  an  assistant  whose  sole  duty  is  to 
administer  the  anaesthetic ;  another  to  assist  in  lifting  out  the 
uterus;  another  to  make  compression  around  the  cervix,  and 
still  another  to  assume  the  charge  of  the  child.  Two  trained 
nurses  will  be  necessary  to  wash  sponges  and  manage  the  irri- 
gating apparatus.  Very  few  instruments  are  necessary  for  this 
operation. 

Two  scalpels,  one  pair  of  laparotomy  scissors,  two  dissect- 
ing forceps,  twelve  artery-clamps,  four  long  compressive  forceps, 
one  groove-director,  one  needle-holder,  six  large  and  six  small 
curved  needles,  a  Koeberle  ecraseur,  and  a  steel  dilator  should 
complete  the  list.  A  perfectly-new  fountain-syringe  with  a 
glass  tube  will  answer  every  purpose  as  an  irrigator.  There 
should  be  in  readiness  eighteen  sterilized  towels. 

In  place  of  sponges,  pads  made  of  absorbent  gauze,  large 
and  small,  and  sterilized,  should  be  used.  These  should  be 
counted  before  the  operation  and  just  before  the  abdominal 
cavity  is  closed.  Five  yards  of  10-per-cent.  iodoform  gauze, 
cut  in  strips  three  inches  wide  and  sterilized,  should  be  at  hand 
for  intra-uterine  tamponade  if  such  prove  necessary.  A  piece 
of  rubber  drainage-tubing,  three-eighths  of  an  inch  in  diameter 
and  one  yard  long,  should  be  boiled  and  held  in  readiness  in 
case  manual  compression  should  fail  to  control  haemorrhage. 
Two  sizes  of  silk  (Nos.  4  and  2),  silk-worm  gut,  and  some  fine 
catgut  should  be  prepared. 

All  instruments  and  ligatures,  except  catgut,  should  be 
boiled  immediately  preceding  the  operation  and  placed  in  trays 


CESAREAN     SECTION.  135 

containing  sterilized  water.  The  operator,  his  assistants,  and 
nurses  must  pay  special  attention  to  rendering  their  hands 
aseptic.  Tliorough  scrubbing  with  soap  and  water,  washing 
the  hands  in  alcohol  and  then  a  five-minute  immersion  in  1  to 
1000  solution  of  bichloride  of  mercury  will  accomplish  this. 
The  operator  and  his  assistants  should  wear  perfectly-clean 
operating-gowns,  or,  if  these  are  not  at  hand,  freshly-Iaundried 
sheets  can  be  used  in  their  stead.  It  is  the  duty  of  the  operator 
to  see  that  his  assistants  do  not  touch  anything  which  has  not 
been  rendered  aseptic  after  they  have  disinfected  their  hands, 
without  repeating  the  scrubbing  process  before  they  assist  in 
the  operation. 

Where  the  operation  is  one  of  election  and  there  is  time 
for  thorough  preparation,  the  patient  should  be  prepared  in  the 
same  way  as  if  laparotomy  for  any  other  purpose  was  to  be 
performed.  A  mild  laxative  for  two  or  three  days  previous  to 
the  operation  should  be  administered.  On  the  evening  pre- 
vious to  the  operation  the  pubic  region  should  be  shaved  and 
thoroughly  washed.  A  compress  which  has  been  wrung  from 
a  solution  composed  of  1  part  of  the  tincture  of  green  soap  and  3 
parts  of  water  is  placed  over  the  abdomen  and  held  in  place  by 
means  of  an  abdominal  binder.  The  next  morning  the  patient 
is  given  an  enema  of  soap-suds  and  a  vaginal  douche  of  1  to 
3000  bichloride-of-mercury  solution.  The  towel  is  removed  and 
the  entire  surface  of  the  abdomen  is  washed  with  95-per-cent. 
alcohol  and  afterward  with  1  to  1000  bichloride-of-mercury 
solution.  A  piece  of  damp  bichloride  gauze  should  be  placed 
over  the  abdomen  and  confined  by  a  few  turns  of  a  roller 
bandage ;  this  the  patient  should  wear  to  the  operating-room. 
She  should  be  catheterized  immediately  before  the  operation. 

When  the  patient  is  brought  to  the  operating-room  she 
should  be  placed  on  a  firm  table,  in  the  dorsal  position  with  the 
knees  slightly  flexed.  The  upper  and  lower  parts  of  the  body 
should  be  covered  over  with  pieces  of  new  rubber  cloth,  and 
these  in  turn  be  covered  with  sterihzed  towels.     The  abdominal 


136  OBSTETRIC    SURGERY. 

dressing-  is  removed  and  the  abdomen  again  Avasbed  witb 
bichloride-of-mercury  solution  1  to  1000.  The  operator,  stand- 
ing on  tbe  patient's  ligbt,  makes  tbe  ordinary  laparotomy  in- 
cision, extending  tbrougb  all  tbe  layers  of  tbe  abdominal  wall. 
This  incision  can  now  be  safely  enlarged,  to  a  point  about  four 
incbes  above  tbe  umbilicus,  witb  tbe  scissors,  using  tbe  fingers 
of  tbe  left  band  to  protect  tbe  intestines.  Five  or  six  beavy 
silk  sutures  sbould  be  passed  tbrougb  tbe  upper  tbree-iburtbs 
of  tbe  abdominal  incision  and  left  untied.  Tbe  uterus  sbould 
now^  be  turned  out  of  tbe  abdominal  cavity.  Tins  is  easily 
accomplisbed  if  it  is  drawai  toward  tbe  operator  so  tbat  its  left 
border  is  made  to  appear  in  tbe  wound  and  tben  depressing  tbe 
abdominal  wall  underneatb  it.  Tbe  temporary  silk  sutures  are 
now  to  be  tigbtened,  care  being  taken  tbat  no  loop  of  intestine 
is  caugbt  witbin  tbeir  grasp.  Tbe  uterus  is  enveloped  in  warm 
sterilized  towels  and  beld  by  tbe  assistant.  Sterilized  absorbent 
gauze  is  placed  around  tbe  lower  segment  of  tlie  uterus  and 
over  tbe  abdominal  incision,  so  tbat  no  blood  or  otber  fluid  may 
enter  tbe  abdominal  cavity.  A  second  assistant  grasps  tbe 
lower  segment  of  tbe  uterus  wdtb  botb  bands  ligbtly,  prepared 
to  control  baemorrbage  by  manual  pressure  if  such  become 
necessarv.  It  is  preferred  by  some  to  control  tbe  uterine  blood- 
supply  by  means  of  a  rubber  ligature  passed  around  tbe  lower 
segment  of  tbe  uterus ;  but  inasmuch  as  this  nearly  always 
causes  serious  injury  to  tbe  peritoneum  and  does  not  control  tbe 
bsemorrbage  any-  better  than  can  be  done  man-ually,  it  is  not 
advisable. 

Tbe  uterus  is  to  be  opened  by  making  a  45-inch  incision 
throuab  tbe  median  line  of  its  anterior  surface,  embracino-  tbe 
middle  third  of  its  length.  Tbe  assistant  wdio  is  grasping  tbe 
lower  segment  of  tbe  uterus  sbould  compress  it  firmly  at  this 
time,  to  control  tbe  haemorrhage  from  tbe  uterine  wall. 

Tbe  incision  sbould  be  made  rapidly,  and  if  tbe  placenta 
is  attached  anteriorly  it  sbould  be  pushed  to  one  side  and  tbe 
child  extracted.     As  soon  as  the  child  is  withdrawn,  tbe  assist- 


CESAREAN     SECTION.  137 

ant  whose  duty  it  is  to  take  charge  of  it  should  clamp  the 
cord  with  two  compression  forceps,  cut  the  cord,  and  remove 
the  child.  Tlie  operator  at  once  turns  his  attention  to  the  pla- 
centa, and,  if  it  is  adherent,  rapidly  peels  it  off.  All  portions 
of  placental  tissue  should  be  carefully  removed.  It  is  frequently 
a  wise  plan  for  the  assistant  whose  duty  it  is  to  steady  the 
uterus,  as  soon  as  the  child  is  extracted,  to  grasp  the  edges  of 
the  incision  between  his  thumb  and  fingers,  and  in  this  way 
assist  in  controlling  the  haemorrhage  from  the  cut  uterine  tissue. 
At  this  time  an  hypodermatic  injection  of  the  fluid  extract  of 
ergot  should  be  made  into  the  gluteal  region. 

If  the  cervical  canal  will  easily  admit  the  finger,  no  dila- 
tation is  necessary ;  otherwise,  the  steel  dilator  should  be  intro- 
duced through  the  incision  and  the  canal  gently  dilated.  The 
uterus  should  be  packed  temporarily  with  iodoform  gauze, — 10 
per  cent., — and  the  sutures  introduced.  The  uterine  incision 
should  be  carefully  closed  by  means  of  two  sets  of  sutures, — a 
deep  one  of  No.  2  silk,  which  passes  through  all  layers  of  the 
uterine  tissue  except  the  mucous  lining,  and  the  sero-serous 
suture  of  No.  4  silk. 

The  deep  sutures  should  enter  the  uterine  tissue  one-eighth 
of  an  inch  from  the  line  of  the  incision,  and,  passing  diagonally 
outward  into  the  uterine  tissue,  re-appear  just  above  the 
mucous  lining  of  the  uterus.  The  needle  used  for  this  suture 
sliould  be  a  half-curved,  perfectly-round  needle,  possessing  no 
cutting  edge.  These  sutures  should  be  placed  about  one-half 
an  inch  apart.  Time  is  such  an  important  element  in  this 
operation  that  any  device  which  can  safely  be  used  to  expedite 
its  performance  should  be  adopted.  By  threading  the  needle 
with  a  piece  of  silk  sixty  inches  long,  and  passing  the  sutures 
in  the  same  way  as  if  they  were  to  be  continuous,  except  that 
the  loops  be  left  four  or  five  inches  long  and  afterward  cutting 
all  the  loops,  the  sutures  can  be  more  rapidly  introduced  than 
if  each  suture  is  on  a  separate  needle.  This  is  shown  in  Figs. 
61  and  62. 


138 


OBSTETRIC    SURGERY. 


As  soon  as  all  the  deep  sutures  are  in  position,  the  tempo- 
rary tamponade  in  the  uterine  cavity  should  be  removed  and 


Fig.  61. — Showing  Deep  Suture  Passed,  the  Loops  Not  Cut. 

the  endometrium  sponged  out  with  a  weak  creolin  solution.     A 
10-per-cent.  iodoform-gauze   strip,  three  inches  wide  and  one 


Fig.  62.— The  Same,  the  Loops  Cut. 


yard  long,  is  packed  into  the  uterine  cavity.     One  end  of  the 
gauze  should   be   carried  tlirough   the  cervical   canal   into  the 


CESAREAN     SECTION. 


139 


vagina.  This  gauze  not  only  provides  for  freer  drainage,  but  is 
an  additional  safeguard  against  haemorrhage.  During  the  dila- 
tation of  the  cervical  canal  and  the  passage  of  the  gauze  strip, 
the  assistant  who  is  controlling  the  ha3morrhage  by  pressure 
around  the  lower  uterine  segment  relaxes  his  grasp.  He  should 
keep  up  this  pressure,  except  at  these  times,  until  the  deep 
sutures  are  tied. 

The  sutures  which  embrace  the  muscular  structure  of  the 
uterus  are  now  secured  by  three  knots,  after  which  the  ends  are 
cut  short. 

The  sero-serous  sutures  are  of  silk  also,  and  interrupted. 


63. — Suture  of  Uterine  Wound. 


a,  deep  muscular  suture ;  b,  deep  muscular  suture  tied,  with  the  ends  cut  short ;  c,  sero-serous  suture 
passed  over  deep  suture  ;  d,  sero-serous  suture  between  the  deep  sutures,  ready  to  be  tied. 

The  Lembert  stitch  is  the  ideal  one  for  bringing  the  peritoneal 
edges  together.  The  number  is  almost  double  that  of  the  deep 
sutures,  one  drawing  the  peritoneum  directly  over  the  knot  of 
the  deep  suture  and  an  intermediate  one  between  each  deep 
suture.  The  arrangement  of  both  deep  and  sero-serous  sutures 
is  shown  in  Fig.  63. 

As  soon  as  all  the  sutures  have  been  secured  the  temporary 
abdominal  sutures  are  removed  and  the  peritoneal  surface  of 
the  cul-de-sac  of  Douglas  should  be  sponged  out.     If  any  liquor 


140  OBSTETRIC     SURGERY. 

amnii  has  entered  the  peritoneal  cavity  it  will  be  better  to 
sponge  it  out  with  Tliiersch's  solution.  When  the  cavity  is 
sponged  dry  the  abdominal  sutures  should  be  introduced. 

Silk- worm  gut  is,  perhaps,  the  best  material  for  this  pur- 
pose. The  abdominal  walls  are  weakened  to  such  an  extent  by 
reason  of  the  pregnancy  that  unusual  care  must  be  taken  to  pre- 
vent the  occurrence  of  ventral  hernia.  Before  the  suture  is 
passed  the  assistant  should  draw  the  fascia  well  forward  with  a 
pair  of  mouse-toothed  forceps.  This  suture  passes  through  all 
layers  of  the  abdominal  wall,  including  the  peritoneum.  After 
these  sutures  are  passed  the  fascia  on  either  side  of  the  incision 
should  be  united  by  means  of  silk-worm-gut  sutures,  secured 
bv  three  knots,  and  the  ends  cut  short.  The  deep  sutures  are 
now  tied,  and  intermediate  approximation  sutures  used  if 
necessary. 

An  antiseptic  dressing  should  be  placed  over  the  wound  and 
secured  by  a  closely-fitting  abdominal  binder.  If  at  the  con- 
clusion of  the  operation  the  patient's  pulse  is  weak  and  rapid, 
an  enema  of  whisky  and  hot  salt  water  should  be  given  before 
she  is  removed  from  the  table.  The  patient  should  be  put  to 
bed  and  external  heat  applied  to  the  extremities. 

Nothing  should  be  given  the  patient  by  mouth  during  the 
first  twelve  hours  following  the  operation  except  small  quan- 
tities of  hot  water  to  relieve  the  thirst.  If  she  suffer  much 
pain,  she  may  be  given  a  small  dose  of  morphine  hypodermat- 
ically.  At  the  end  of  the  first  twelve  hours,  if.  she  has  ceased 
to  experience  nausea  from  the  ether,  small  quantities  of  milk 
and  lime-water  can  be  given,  which  can  gradually  be  increased 
according  to  circumstances. 

An  attempt  should  be  made  to  move  tlie  patient's  bowels  as 
soon  as  any  untoward  symptoms,  such  as  a  rapid  pulse,  undue 
rise  of  temperature,  vomiting,  or  abdominal  distension  develop. 
Otherwise  the  bowels  should  not  be  moved  until  the  third  day 
after  the  operation. 

Calomel  triturates,  J  grain  each,  can  be  given  for  this  pur- 


CESAREAN     SECTION.  141 

pose  every  hour  for  six  doses.  This  should  be  followed  by  a 
simple  enema. 

The  patient  should  receive  nothing  but  liquid  nourishment 
during-  the  first  week  after  the  operation.  The  ordinary  anti- 
septic pad  should  be  placed  over  the  vulva  and  renewed  as 
necessary.  The  intra-uterine  drain  should  be  removed  on  the 
second  or  third  day.  Should  the  flow  at  any  time  be  excessive, 
hypodermatic  injections  of  ergot  should  be  used.  Under  no 
circumstances  must  the  patient  be  allowed  to  assume  the  sitting 
posture  during  the  first  ten  days. 

The  abdominal  sutures,  except  those  which  unite  the 
fascia,  should  be  removed  on  the  tenth  day,  and  with  the  same 
care,  as  regards  asepsis,  as  when  they  were  introduced.  The 
abdominal  binder  should  be  worn  for  one  year  after  the  section 
is  performed.  Unless  some  complication  prolongs  the  convales- 
cence, the  patient  should  be  up  and  around  her  room  at  the 
end  of  three  weeks. 

This  is  the  method  of  conducting  the  elective  operation, 
and,  if  the  patient  be  in  good  general  condition  and  the  various 
little  details  of  aseptic  surgery  are  appreciated  and  executed, 
the  patient  should,  without  any  doubt,  recover. 

If,  however,  the  operation  is  performed  as  a  last  resort, 
after  perhaps  thirty  or  more  hours  of  labor,  when  the  patient's 
vital  forces  are  greatly  lowered  from  her  own  and  her  phy- 
sician's unsuccessful  attempts  at  delivery,  the  outlook  is  by  no 
means  so  encouraging.  On  the  other  hand,  the  mortality  in 
just  such  cases  is  great,  as  is,  in  fact,  any  other  operation  which 
may  be  attempted. 

Ti  AP  A  RO-HTSTERECTOMY. 

Before  the  perfection  of  the  method  of  performing  Csesarean 
section  as  it  is  done  to-day,  the  mortality  rate  was  so  high  that 
an  attempt  was  made  to  eliminate  the  uterine  cavity  as  a  pos- 
sible source  of  infection,  by  removing  the  uterus  after  the  child 
had  been  extracted.     This  was,  without  doubt,  a  great  advan- 


142  OBSTETRIC     SURGERY. 

tao-e  over  the  old  method  of  either  not  closmg  the  uterine 
incision  at  ah  or  else  very  imperfectly  so. 

The  operation  should  not  be  performed  at  the  present  time 
not  oiilv  on  account  of  the  greater  and  unnecessary  mutilation, 
but  also  on  account  of  the  increased  risk  to  the  patient,  unless 
there  be  some  verv  well  defined  indication.  If  the  Csesarean 
section  is  performed  on  a  uterus  whose  endometrium  is  already 
the  site  of  sepsis,  or  if  multiple  interstitial  tibroids  complicate 
the  case,  or  if  such  marked  uterine  inertia  persist  that  loss  of 
life  from  haemorrhage  seems  imminent,  then  the  entire  removal 
of  the  uterus  is  indicated. 

Oijeration  — Exactly  the  same  preparations  as  have  been 
sug-CTested  in  Ctesarean  section  should  be  made  in  case  total 
ablation  of  the  uterus  is  to  be  performed,  except  that  a  greater 
number  of  long  compression  clamps  and  a  large  piece  of  thin 
rubber  sheetin"-.  such  as  is  used  by  dentists,  should  be  at  hand. 
The  detail-  of  the  operation  are  the  same  as  in  Ctesarean  section 
until  the  uterus  lias  been  turned  out  of  the  peritoneal  cavity. 
At  this  time,  instead  of  ushig  manual  compression,  a  piece  of 
rubber  tubins:  should  be  passed  around  the  lower  uterine  seg- 
ment and  loosely  tied  with  one  knot.  A  small  opening  is  now 
made  in  the  rubber  sheeting,  which  should  be  made  to  encircle 
the  uterus  just  above  the  rubber  tubing.  The  elasticity  of  the 
rubber  sheeting-  will  cause  it  to  ht  closely  around  the  uterine 
tissue  and  prevent  any  lluid  from  the  uterus  entering  the  peri- 
toneal cavitv.  AVitli  every  thing  in  readiness  the  assistant 
draws  on  the  ends  of  the  rubber  tubing  until  the  circulation  is 
cut  off.  The  operator  at  tlie  same  time  hastily  opens  the  uterus 
and  extracts  the  child.  The  placenta  is  detached  and  the 
uterus  amputated  just  above  the  rubber  sheeting  with  the 
scalpel.  If  the  endometrium  has  been  the  site  of  septic  infec- 
tion great  care  must  be  taken  that  no  fluids  enter  the  peritoneal 
cavitv.  The  stump  above  the  rubber  tubing  should  be  carefully 
disinfected  and  seared  Avith  the  Parprelin  cautery.  If  the  patient 
is  in  poor  condition  from  either  sepsis  or  other  causes.it  is  better 


CESAREAN     SECTION.  143 

to  treat  the  stump  extra-peritoiieally,  inasmuch  as  tliis  shortens 
the  operation  and  lessens  shock.  If  the  stump  is  to  be  treated 
extra-peritoneally  for  the  reasons  ah'eady  given,  the  wire  loop  of 
the  Koeberle  ecraseur  should  be  passed  around  the  stump  just 
below  the  rubber  tubing.  It  is  necessary  to  see  that  no  portion 
of  the  bladder  is  caught  within  the  grasp  of  the  loop.  This  acci- 
dent can  be  easily  prevented  if  a  sound  is  passed  into  the  bladder 
to  clearly  define  its  attachment  to  the  anterior  wall  of  the  cervix. 
The  stump  should  be  firmly  compressed  with  the  wire  loop 
until  the  tissues  are  blanched.  The  stump  should  then  be 
trimmed  until  it  is  three-fourths  of  an  inch  above  the  wire. 
The  rubber  tubing  is  removed  as  soon  as  the  wdre  is  tightened. 
The  stump  should  again  be  cauterized  and  the  two  lAns  which 
accompany  the  ecraseur  passed  through  the  stump,  just  above 
the  wire,  at  right  angles  to  the  abdominal  wound.  The  peri- 
toneum should  now  be  stitched  with  catgut  around  the  stump. 
The  cul-de-sac  of  Douglas  should  be  carefully  sponged  out  and 
the  abdominal  wall  closed. 

The  operation  is  completed  by  powdering  the  stump  with 
iodoform  and  applying  the  usual  antiseptic  dressings  to  the  ab- 
dominal wound.  The  stump,  which  of  necessity  sloughs  away, 
renders  the  convalescence  tedious  and  the  dressings  frequent. 
The  stump  comes  away  in  ten  or  twelve  days  and  leaves  a 
granulating  surface.  If  the  cervix  is  now  dilated  and  in  tliis 
way  we  permit  drainage  from  below,  the  wound  will  heal  much 
more  rapidly.  A  piece  of  gauze  can  be  passed  from  above 
through  the  cervical  canal  into  the  vagina.  If,  however,  the 
patient's  general  condition  be  good,  and  if  the  operation  is 
determined  upon  from  an  elective  stand-point,  so  that  ample 
preparations  can  be  made,  and  if  the  uterine  body  is  the  site 
of  multiple  fibroids,  then  the  entire  uterus,  together  with  the 
cervix,  should  be  removed.  In  this  case,  as  soon  as  the  uterus 
is  amputated  and  the  field  of  operation  disinfected,  the  assistant 
secures  the  rubber  tubing  by  tying  a  double  knot.  The  operator 
then  proceeds  to  free  the  bladder  from  the  anterior  surface  of 


144  OBSTETRIC     SURGERY. 

the  lower  uterine  segment.  This  can  be  easily  and  rapidly  done 
by  incising  the  peritoneum  just  above  the  bladder-fold  and 
stripping  the  bladder-attachment  off  Avith  the  finger.  The 
broad  ligament  should  now  be  secured  on  either  side  by  means 
of  very  strong  silk  ligatures.  By  palpation  the  uterine  artery 
can  be  found  and  secured.  The  vaginal  attachments  to  the 
cervix  should  be  cut  through  and  the  stump  removed.  Any 
bleeding-points  should  be  caught  in  the  forceps  and  ligated. 
The  ligatures  should  all  be  left  long,  and  as  soon  as  all  haemor- 
rhage is  controlled  the  ends  of  the  ligatures  should  be  passed 
into  the  vaginal  opening.  Iodoform  gauze  should  be  packed 
in  the  supravaginal  space,  and  the  peritoneum  closed  by  sewing 
the  anterior  peritoneal  layer  of  the  cul-de-sac  to  the  peritoneal 
covering  of  the  bladder  with  a  continuous  catgut  ligature.  In 
this  way  the  raw  surface  is  placed  entirely  extra-peritoneally. 
The  pelvis  is  carefully  sponged  and  the  abdominal  wound 
closed.  There  is  no  necessity  for  drainage  from  above.  The 
after-treatment  should  be  the  same  as  for  Csesarean  section. 

Laparo-elttrotomy. 

The  operation  for  removing  the  foetus  through  an  incision 
in  the  flank  possessed  advantages  at  tlie  time  when  antisepsis 
and  asepsis  were  unknown,  inasmuch  as  it  obviated  the  neces- 
sity of  opening  the  peritoneal  cavity.  The  improved  Caesarean 
section  is  so  much  easier  of  accomplishment,  and  is  fraught  with 
so  much  less  danger,  that  the  necessity  for  this  method  no  longer 
exists. 

Prognosis. — There  is  no  obstetric  operation  in  which 
elective  surgery  plays  a  greater  role  in  determining  the  prog- 
nosis than  the  one  under  consideration.  Where  the  Caesarean 
section  is  only  determined  upon  after  forceps  and  version  have 
failed,  the  woman  being  exhausted  and  the  child  as  well,  the 
mortality  rate  is  necessarily  high.  The  elective  Caesarean  sec- 
tion, on  the  other  hand,  so  simple  and  so  accurate  is  its  tech- 
nique, subjects  the  woman  to  but  one  risk,  and  this  is  septic 
infection. 


CESAREAN    SECTION.  145 

The  Csesarean  section  should  alone  be  judged  by  its  modern 
fruits.  The  mortality  rate  in  the  past,  ranging  from  30  to  50 
per  cent.,  was  due  either  to  faulty  technique  or  to  sepsis.  At 
the  present,  when  the  advantage  of  predetermining  the  opera- 
tion is  recognized,  the  death-rate,  as  is  noted,  barring  septic  in- 
fection, has  been  lowered  approximately  to  that  which  is  asso- 
ciated with  difficult  embryotomy. 

The  latest  statistics,  as  collated  by  Robert  P.  Harris,  are 
the  following:  Of  13  cases  where  the  operation  was  performed 
before  labor  had  begun,  10  women  recovered  and  13  children 
were  saved ;  of  6  cases  where  the  operation  was  performed  at 
the  beginning  of  labor,  6  women  recovered  and  6  children  were 
saved  ;  of  1  "2  cases  where  the  women  had  been  in  labor  from 
two  to  six  hours,  10  recovered  and  11  children  were  saved; 
of  18  cases  where  the  women  had  been  in  labor  from  seven  to 
twelve  hours,  8  recovered  and  13  children  were  saved. 

These  figures  speak  most  eloquently  in  favor  of  the  elect- 
ive, predetermined,  Csesarean  section.  Two  of  the  three  deaths 
in  the  category  where  the  operation  was  performed  before  labor 
had  begun  were  due  to  septic  infection,  and  the  third  succumbed 
to  secondary  haemorrhage. 

The  record  of  individual  operators  in  the  United  States 
and  abroad  surpasses  the  above  statistical  data,  giving  us,  in 
general,  a  mortality  rate  varying  from  nil  to  10  per  cent. 

The  result  of  asepsis  and  of  election,  then,  has  been  to 
place  the  modern  Caesarean  section  on  the  same  plane  as 
other  major  surgical  operations,  with  the  addition  of  saving 
from  90  to  95  per  cent,  of  infantile  lives  otherwise  infallibly 
doomed. 

As  regards  the  Porro  operation,  the  prognosis  Avill  probably 
always  remain  gloomier  owing  to  the  extra  complications  which 
necessitate  resort  to  it.  The  mortality  rate,  however,  has  been- 
in  recent  times  lowered  to  about  25  per  cent. 


CHAPTER  VII. 
EMBRYOTOMY. 

Under  the  term  "embryotomy"  are  included  a  number 
of  operative  procedures  which  have  received  distinctive  names, 
but  the  uniform  aim  of  which  is  to  deliver  the  foetus  per  vias 
naturales  after  its  mutilation  to  a  greater  or  a  less  degree.  In 
modern  times  the  sphere  of  these  operations  has  been  greatly 
narrowed,  owing  to  the  perfection  in  technique  and  in  results 
of  induced  labor  and  of  Cesarean  section  on  the  one  hand,  and 
owing  to  the  resuscitation  and  elevation  to  a  scientific  plane  of 
symphysiotomy  on  the  other  hand. 

Embryotomy,  generically  considered,  includes  the  following 
operative  procedures :  1.  Craniotomy.  2.  Cephalotripsy.  3. 
Evisceration.     4.  Decapitation. 

In  general  the  indications  for  these  operations  are:  1. 
Contracted  pelvis,  the  foetus  being  dead  or  non- viable  and  the 
conjugate  diameter  measuring  above  two  and  one-half  inches. 

2.  Obstructed  labor,  due  to  monstrosity  or  to  hydrocephalus. 

3.  Impacted  shoulder  presentation,  impacted  after-coming  head, 
or  irreducible  face  presentation,  the  foetus  being  dead. 

It  will  be  noted  that  under  these  indications  the  proviso  is 
made  that  the  foetus  be  dead,  except  when  dealing  with  mon- 
strosities. Our  reason  for  such  proviso  is  the  belief,  stringently 
insisted  upon  throughout  this  treatise,  that,  the  maternal  con- 
dition not  contra-indicating  in  the  manner  sufficiently  dwelt 
upon  in  the  chapters  on  the  Caesarean  section  and  symphysi- 
otomy, recourse  to  these  operations  will  usually  be  justifiable, 
and  embryotomy  of  the  live  foetus  rarely  be  so.  This,  at  any 
rate,  has  become  the  modern  rule  in  maternity  hospitals. 

In  private  practice  the  question  still  remains  open  to  the 
choice  of  the  patient,  and  will  so  remain  until  the  Csesarean 
section  becomes  as  safe  an  operation  as,  in  the  hands  of  an  ex- 
(146) 


EMBRYOTOMY.  147 

pert,  embryotomy  should  be.  In  a  given  case,  however,  it  is 
the  bounden  duty  of  the  physician  to  set  the  relative  stand- 
points of  the  two  operations  impartially  before  the  woman. 
Neither  sentimentality  nor  religious  training  or  belief  should 
swerve.  To  speak  as  definitely  as  possible,  the  woman's  chances 
of  recovery  under  embryotomy  are  fully  nine  out  of  ten,  but 
then  she  loses  her  child ;  under  the  Csesarean  section  the 
chances  against  her  are  two  out  of  ten,  whilst  the  child's 
chances  of  survival  are  nine  out  of  ten.  This  fair  estimate  is, 
of  course,  based  on  the  assumption  that  the  Csesarean  section  is 
an  elective  one,  and,  further, — a  point  to  be  well  noted, — that 
the  embryotomy  of  the  living  foetus  is  not  an  elective  one,  for 
embryotomy  under  this  condition  will  never  become  strictly 
elective.  Where  the  Csesarean  section  is  not  going  to  be  taken 
into  consideration,  the  average  physician,  outside  of  a  hospital, 
will  attempt  every  other  possible  procedure  beibre  deliberately 
electing  an  operation  which  entails  the  taking  of  life,  even 
though  it  be  to  save  life.  This  is  an  absolutely  erroneous 
working  basis.  AVhere  the  cause  of  the  pelvic  dystocia  is 
recognized,  our  science  is  well-nigh  exact  enough  to  enable  the 
properly-trained  physician  to  predicate  the  chance  of  delivery  of 
the  live  foetus  of  average  size  by  means  of  the  non-mutilating 
minor  operations.  Therefore,  due  election  is  as  possible  in  the 
case  of  embryotomy  as  it  is  in  case  of  any  other  obstetric 
operation.  There  is  no  credit  in  delivering  the  woman  by  em- 
bryotomy when  she  is  so  exhausted  as  to  have  but  slight  chance 
of  surviving  the  operation.  In  major  dystocia,  then,  embry- 
otomy of  the  living  foetus  should  be  elected  in  order  to  avoid  a 
single  percentage  of  mortality  rate;  else  the  maternal  chances 
from  the  Csesarean  section  are  far  better  than  from  non-elective 
embryotomy.  That  is  to  say,  where  the  choice  between  the 
two  operations  is  based  on  an  absolute  indication,  the  one  or 
the  other  must  be  deliberately  elected.  It  is  the  border-line 
cases  which  will  always  call  for  the  soundest  judgment,  and 
here,  fortunately,  symphysiotomy  can  stand  between  the  Csesar- 


148 


OBSTETRIC     SURGERY. 


ean  section  and  embryotomy  of  the  living  foetus.  As  is  amply 
emphasized  under  the  subject  of  symphysiotomy,  there  is  to-day 
left  little  ground  for  the  choice  of  embryotomy.  Under  an 
absolute  indication  the  Caesarean  section  is  as  safe  for  the 
woman  as  the  difficult  embryotomy,  and  under  the  relative 
indication  pubic  section  narrows  very  strictly  the  indications  of 
embryotomy.     In  the  near  future,  then,  the  physician  in  private 


Fig.  64.— Braun's  Trephine. 

practice,  as  he  is  now  in  hospital  practice,  may  be  relieved 
of  the  duty  of  killing  the  foetus  in  cases  where,  through  an 
alternate  operation,  both  woman  and  foetus  may  be  saved. 

1.  The  Operation  of  Craniotomy. — This  operation,  as  the 
name  implies,  aims  at  diminishing  the  bulk  of  the  foetal  skull. 
It  is  performed  either  on  the  before-coming  or  on  the  after- 
coming  head.  In  the  latter  event  it  will  rarely  become  a  ques- 
tion of  killing  the  foetus,  since  the  child  will  usually  be  dead 
before  craniotomy  is  demanded.     At  best,  craniotomy  must  be 


Fig.  65.— Blot's  Perforator. 

considered  a  difficult  operation.  The  working  room  is  slight 
owing  to  the  contraction  of  the  pelvis  ;  for  the  same  reason  the 
cervix  is  rarely  fully  dilated  ;  injury  to  the  maternal  parts  is  not 
an  unlikely  occurrence,  and  this  traumatism  increases  greatly 
the  risk  from  septic  infection  or,  in  any  event,  will  complicate 
the  convalescence. 

The  essential  instruments  requisite  for  the  performance  of 


EMBRYOTOMY. 


149 


craniotomy  are  :  A  trephine  for  perforation  ;  a  cranioclast  for 
extraction.  There  are  a  number  of  types  of  perforators,  such 
as  Karl  Braun's  trephine,  Blot's  perforator,  Martin's  trephine, 
Naegele's  scissors,     Braun's  and  Blot's    instruments    are  par- 


Fig.  66.— Martin's  Trephine. 

ticularly  useful  in  case  the  operation  is  performed  on  the  before- 
coming  head;  the  scissors  answers  best  for  the  after-coming 
head. 

The  head  having  been  perforated,  a  sound  (like  the  uterine 
or,  better  still,  the  metal  urethral)  is  needed  to  break  up  the 


Fig.  67.— Scissors-Perforator. 

brain,  and  a  syringe  to  wash  out  the  contents  of  the  cranium. 
This  accomplished,  the  cranioclast  or  craniotractor — a  better 
term,  since  it  defines  the  purpose  of  the  instrument — comes 
into  play.     The  best  instrument  is  that  of  Karl  Braun. 

The  steps  of  the  operation  are  the  following  :   The  extei'nal 


Fig.  68. — Braun's  Cranioclast. 


genitals  and  the  vagina  having  been  thoroughly  asepticized,  the 
woman  is  placed  on  a  table,  the  bed  not  sufficing  for  any  of  the 
major  obstetric  operations.  The  instruments  are  sterilized  and 
the  hands   of  the   operator  and  of   his   assistant  are  carefully 


150  OBSTETRIC     SURGERY. 

cleansed.  Too  much  care  in  this  respect  is  not  possible,  since 
the  sole  risk  in  expert  hands  to  which  the  woman  is  subjected 
is  septic  infection.  If  the  woman  be  not  excessively  nervous, 
and  the  operative  indication  be  not  an  extreme  one,  ansesthesia 
is  not  absolutely  essential.  In  view,  however,  of  its  safety,  we 
always  counsel  it. 

The  bladder  having  been  emptied  by  catheter,  the  woman 
is  placed  in  tlie  lithotomy  position  and  we  proceed  as  follows: — 

(a)  Craniotomy  of  the  Before-coming  Head. — The  foetal 
head  should  be  steadied  at  the  brim  through  supra-pubic  pressure 
made  by  an  assistant.  The  operator  determines  the  position  of 
tlie  head  through  vaginal  examination  and  selects  the  preferable 
point  for  perforation.  Either  a  parietal  or  the  occipital  bone 
will  be  accessible,  and  one  or  the  other  should  be  chosen, 
sutures  and  fontanelles  being  avoided.  The  fingers  of  the  left 
hand  are  placed  against  the  foetal  head  to  steady  the  trephine 
and  to  guard  against  injury  to  the  maternal  parts.  The  tre- 
phine is  pressed  firmly  against  the  head,  its  handle  is  steadied 
by  the  operator's  right  hand,  and  the  nurse  or  the  second  as- 
sistant turns  the  screw  of  the  trephine  until  the  head  has  been 
entered.  The  trephine  is  now  removed  and  the  metal  sound  is 
inserted  into  the  cranium  to  break  up  the  brain.  The  nozzle  of 
the  syringe  or  a  glass  irrigating  tube,  fitted  to  the  syringe,  next 
takes  the  place  of  the  sound  and  the  brain  is  washed  out. 
(Plate  XIV,  Fig.  1.) 

It  has  been  contended  that  the  preferable  practice  is  now 
to  leave  the  case  to  nature.  We  can  see  no  advantage  in  this. 
The  woman  being  anaesthetized,  it  is  better  to  follow  perforation 
with  extraction.  We  thus  avoid  what  may  prove  futile  effbrts 
on  nature's  part,  and  we  thus  forestall  possible  maternal  ex- 
haustion. The  left  or  grooved  blade  of  Braun's  cranioclast  is 
inserted  into  the  opening  made  by  the  trephine  ;  the  other  blade 
is  applied  to  the  outside  of  the  skull,  being  guided  into  position 
by  fingers  of  the  right  or  left  hand,  according  as  the  blade  is 
r.pplied  to  the  left  or  the  right  of  the  pelvis.     The  blades  are 


PLATE    XJV. 


Fig.    I. — Trephining  the    Before-coming   Head. 


rw.    2. — Perforation    of   the    Af+er-rnmmor    Head. 


EMBRYOTOMY. 


151 


locked ;  the  screw  is  turned  home,  which  results  in  firm  hold  of 
the  head  being  secured.  Traction  is  made,  even  as  with  the 
forceps,  in  the  axis  of  the  pelvic  brim  until  the  head  reaches 
the  pelvic  floor,  and  then  in  the  axis  of  the  pelvic  outlet.  The 
foetus  having-  been  extracted  and  the  placenta  having  been  ex- 
pressed, an  intra-uterine  douche  of  2-per-cent.  creolin  or  of 
1  to  8000  bichloride  solution  is  given. 


Fig.  69.— Effect  of  the  Cranioclast  on  the  Foetal  Skull. 

Where  extraction  by  the  cranioclast  proves  difficult  owing 
to  non-yielding  of  the  occiput,  the  cephalotribe,  as  will  be 
noted,  should  be  substituted.  It  is  to  be  remembered  that 
extraction  by  the  cranioclast  is  possible  because,  the  cranial 
contents  having  been  evacuated,  traction  on  the  head  causes  it 
to  be  compressed,  and  thereby  diminished  by  the  pressure  ex- 
erted by  the  pelvic  walls.  Undue  pressure  is  to  be  avoided  in 
order  to  prevent,  in  turn,  traumatism  of  the  maternal  parts. 


152  OBSTETRIC     SURGERY. 

(b)  Craniotomy  of  the  After-coming  Head. — The  operation 
on  the  after-coming  head  presents  greater  difficulties  than  tliat 
on  the  before-coming  head.  The  trunlv  of  the  foetus  having 
been  extracted,  it  is  in  the  way  of  the  necessary  manipula- 
tions. Only  exceptionally,  also,  will  it  be  possible  to  elect 
the  desirable  point  for  perforation,  this  point  being  the  occipito- 
atloid  ligament.  Further  still,  after  perforation  and  excere- 
bration,  if  the  head  be  wedged  tightly  at  the  brim,  the  greatest 
possible  care  is  requisite,  in  inserting  the  blades  of  the  ex- 
tractor, in  order  to  avoid  inflicting  considerable  traumatism  on 
the  maternal  parts. 

When  possible  to  reacli  the  occipito-atloid  ligament,  the 
scissors-perforator  of  Naegele  is  the  best  instrument.  When 
the  necessities  of  the  case  require  perforation  through  the  dense 
mastoid  or  occipital  bone,  the  perforator  of  Martin  or  of  Blot, 
being  smaller  than  the  trephine  of  Braun,  should  be  selected. 

The  steps  of  the  operation  are  as  follow :  After  thorougli 
asepsis  of  the  genital  tract  and  emptying  of  the  bladder,  one 
assistant  steadies  the  head  by  suprapubic  pressure,  and  a 
second  pulls  the  trunk  of  the  foetus  laterally,  downward  or 
upward,  according  as  the  operator  has  decided  to  perforate 
under  the  pubes,  to  one  or  the  other  side  of  the  pelvis,  or  from 
below  upAvard.  If  the  occiput  has  been  rotated  under  the 
pubes,  as  it  ordinarily  may,  the  operator  determines  wdth  the 
finger  the  occipito-atloid  articulation,  and  guides  the  scissors 
along  tills  finger  to  the  site.  The  finger  must 'remain  in  po- 
sition during  perforation,  in  order  to  protect  the  bladder  in  the 
event  of  the  scissors  slipping.  The  wedge  of  the  scissors 
having  been  entered  at  the  articulation,  pressure  on  the  handles 
enlarges  the  opening  into  the  cranium  laterally,  and  next,  by 
rotation  of  the  scissors,  similar  pressure  enlarges  the  opening 
ante.ro-posteriorly.  This  having  been  effected,  the  scissors  is 
removed  and  the  metal  sound  is  inserted  for  the  purpose  of 
breaking  up  the  brain.  The  contents  of  the  cranium  are  next 
washed  out  with  sterilized  water  thrown  in  by  the  syringe.     If 


EMBRYOTOMY.  153 

the  pelvic  contraction  be  not  marked  and  uterine  contractions 
are  active,  the  excerebrated  head  may  be  born  spontaneously.  As 
a  rule,  however,  extraction  by  the  cranioclast  is  essential.  The 
left,  grooved  blade  of  Braun's  cranioclast  is  inserted  into  the 
cranial  cavity,  the  right  blade  is  applied  laterally,  the  instru- 
ment is  locked,  and  the  screw  is  turned  home.  Traction  is 
made  in  the  axis  of  the  pelvic  inlet  or  outlet,  according  to 
whether  the  head  is  in  the  cavity  or  on  the  pelvic  floor.  (Plate 
XIV,  Fig.  2.) 

If  the  position  of  .the  head  is  such  that  the  occipito-atloid 
ligament  cannot  be  reached,  it  becomes  necessary  to  enter  the 
skull  through  an  opening  made  in  one  or  another  of  the  cranial 
bones,  and  then  the  scissors-perforator  will  not  answer.  Either 
Blot's  or  Martin's  instrument  is  firmly  applied  to  the  point 
selected  for  perforation,  and  the  skull  is  trephined.  The  other 
steps  are  similar  to  those  just  stated. 

At  times  the  foetal  head  is  extended  at  the  outlet,  so  that 
practically  we  are  dealing  with  an  impacted  face  presentation. 
Under  these  circumstances  the  skull  may  be  entered  with  the 
scissors-perforator  through  the  roof  of  the  mouth. 

Exceptionally,  owing  to  density  of  the  cranium,  it  becomes 
impossible  to  extract  with  the  cranioclast.  Then,  as  will  be 
noted,  it  becomes  necessary  to  resort  to  cephalotripsy. 

The  operation  of  craniotomy  having  been  completed  and 
the  placenta  having  been  expressed,  an  intra-uterine  douche  of 
2-per-cent.  creolin  or  of  I  to  8000  bichloride  solution  should  be 
administered.  In  the  event  of  injury  having  been  inflicted  on 
the  pelvic  floor,  the  same  should  be  repaired. 

2.  The  Operation  of  GepliaJotripsy. — The  aim  of  this  oper- 
ation is  to  crush  the  skull  in  order  to  allow  of  readier  extraction 
than  is  possible  in  certain  instances  by  means  of  the  cranioclast. 
The  latter  instrument  is  a  tractor,  pure  and  simple ;  the  cephal- 
otribe  is  at  the  outset  a  crusher  and  afterward  a  tractor.  Per- 
foration is  as  essential  an  initial  step  as  in  a  case  of  craniotomy. 
The  advantage,  therefore,  which  the  cephalotribe  has  over  the 


154 


OBSTETRIC     SURGERY. 


cranioclast  is  that,  being  a  more  powerful  instrument,  it  enables 
the  operator  to  overcome  the  difficulties  in  the  way  of  delivery 
by  the  simple  tractor  offered  by  a  dense  and  fully-ossified  cra- 
nium. The  cephalo tribe,  however,  has  the  disadvantage  of 
being  a  bulkier  instrument  than  the  cranioclast,  and,  further, 


Fig.  70.— Lusk's  Cephalotiibe. 

occupies  more  space  in  the  pelvis,  since  neither  of  the  blades  is 
applied  within  the  cranial  cavity.  For  this  reason,  therefore, 
the  cranioclast  is  to  be  preferred  whenever  the  emergencies  of 
the  given  case  will  allow  of  its  application. 

Simpson,  Hicks,  Breisky,  lAisk,  and  others  have  devised 
useful  forms  of  the  instrument.     Lusk's  cephalotribe,  in  most 


Fig.  71.— Tarnier's  Basiotribe. 


respects,  will  answer  best  where  the  instrument  is  indicated 
at  all.  Obviously,  since  the  cephalotribe  is  applied  entirely 
between  the  walls  of  the  pelvis  and  the  foetal  head,  and  since, 
further,  the  instrument,  whilst  diminishing  the  diameter  of  the 
head  in  one  direction,  increases  it  in  another,  is  applicable  only 


EMBRYOTOMY.  155 

when  the  operation  is  indicated  in  the  presence  of  the  minor 
grades  of  pelvic  contraction. 

Exceptionally,  even  this  instrument  is  not  powerful  enough 
to  break  up  the  base  of  the  cranium  to  permit  of  delivery  with- 
out subjecting  the  maternal  parts  to  unnecessary  damage.  Then 
we  must  have  recourse  to  the  rather  complicated,  but  most 
powerful,  instrument  devised  by  Tarnier, — the  basiotribe.  This 
instrument  is  a  perforator  and  a  cephalotribe  in  one.  The 
screw-tip  perforates  the  cranium  and  holds  it  firmly  whilst  the 
action  of  the  blades  is  crushing  the  base  of  the  skull. 

Notwithstanding  its  advantages  in  certain  cases,  the  cepha- 
lotribe is  a  more  dangerous  instrument  than  the  cranioclast. 
Injury  to  the  maternal  parts  is  more  likely  owing  to  the  in- 
creased room  in  the  pelvis  its  use  entails ;  and,  further,  owing  to 
the  spicula  of  bone  which  are  apt  to  project  as  the  result  of  the 
crushing  force  applied.  Still,  the  instrument  is  a  most  essential 
one  in  fortunately  rare  instances. 

The  initial  steps  of  cephalotripsy  are  similar  to  those  for 
craniotomy, — thorough  asepsis  of  the  genital  tract,  hands  of 
operator  and  assistant  and  instruments,  followed  by  perforation 
and  excerebration.  The  blades  of  the  ceplialotribe  are  next 
applied  accurately  to  the  foetal  head,  under  the  guidance  of  the 
fingers  in  the  vagina.  The  screw  is  then  turned  home  and  the 
cranium  is  crushed,  being  elongated  in  the  diameter  opposed  to 
to  that  in  which  the  crushing  force  is  exerted.  This  latter 
point  is  ever  to  be  borne  in  mind,  so  that  during  tlie  process  of 
extraction  the  enlarged  diameter  of  the  foetal  skull  may  be  ro- 
tated, where  choice  exists,  into  the  larger  diameter  of  the  pelvis. 
Extraction  is  made  even  as  with  the  forceps,  in  the  axis  of  the 
inlet,  until  the  head  reaches  the  pelvic  floor,  and  then  in  the 
axis  of  the  outlet.  After  delivery  of  the  Ibetus  and  the  placenta, 
an  intra-uterine  douche  of  2-per-cent.  creolin  or  1  to  8000  bi- 
chloride solution  is  to  be  administered,  and  any  injury  to  tlie 
pelvic  floor  is  to  be  repaired. 

3   and   4.    Evisceration  and  Decapitation. — These   opera- 


156  OBSTETRIC     SURGERY. 

tions  are  applicable  to  instances  where  the  fcetus  lies  trans- 
versely in  the  uterus,  and  impacted  to  such  a  degree  as  to 
forbid  version,  for  the  purpose  of  bringing  the  foetal  head  in 
such  relation  to  the  pelvic  brim  as  to  permit  of  craniotomy. 

Evisceration  is  called  for  where  the  neck  of  the  foetus 
cannot  be  reached,  whereas,  when  it  can  be  reached,  decapita- 
tion finds  its  sphere  of  action.  Both  these  operative  procedures 
must  be  considered  as  welj-nigh  the  most  dangerous  of  all  ob- 
stetric operations.  Aside  from  the  increased  risk  of  direct  trau- 
matism to  the  uterus,  in  which  organ,  necessarily,  the  manipula- 
tions take  place,  the  lower  uterine  segment  is  usually  thinned, 
particularly  in  neglected  cases,  and,  therefore,  there  exists 
considerable  likelihood  of  rupture  of  the  uterus. 

Where  the  neck  of  the  uterus  is  not  accessible  and  evis- 
ceration becomes  the  operation  of  necessity,  the  steps  are  as 
follow :  After  thorough  asepsis  of  the  genital  tract,  and  similar 
precautions  in  regard  to  the  hands  of  the  operator,  his  assistants, 
and  the  requisite  instruments,  the  scissors-peribrator  is  guided 
along  one  or  more  fingers  in  the  vagina  to  the  most  accessible 
portion  of  the  foetal  trunk,  is  inserted  to  its  full  depth,  and  the 
opening  thus  made  is  enlarged  by  pressure  on  the  handles. 
The  metallic  sound  is  next  inserted  into  this  opening,  and  the 
contained  organs  are  broken  up.  This  process  is  tedious  and 
calls  for  extreme  caution  lest  the  sound  perforate  the  foetus,  and 
thus  inflict  damage  on  the  uterus.  Whenever  possible  the 
finger  of  the  operator  should  take  the  place  of  the  sound.  The 
cavity  having  been  emptied  of  its  contents,  any  projecting  spic- 
ulse  of  bone  are  removed  by  the  bone-forceps,  and  then  the  foetal 
trunk  may  possibly  be  bent  on  itself  through  traction  applied 
by  the  blunt  hook,  and  be  thus  delivered.  Should  this  manipu- 
lation fail,  the  operator  will  be  obliged  to  break  the  foetus  up 
further,  dismembering  it,  and  resorting  to  the  cranioclast  or  to 
the  cephalotribe  for  the  extraction  of  the  foetal  head.  A  num- 
ber of  complicated  instruments,  such  as  chain-saws,  have  been 
devised  for  use  in  these  extreme  instances ;   but  they  are  one 


EMBRYOTOMY. 


157 


and  all  open  to  the  objection  that,  being  difficult  to  apply 
around  the  foetal  trunk,  they  are  liable  to  inflict  great  damage 
on  the  maternal  structures.  A  simple  device  is  the  follow- 
ing :  When  possible  a  sterilized  gum-elastic  catheter,  threaded 
through  its  eye  with  a  stout  sterilized  cord,  is  carried  around 
the  trunk  of  the  foetus.  The  catheter  is  unthreaded  and  re- 
moved, leaving  the  cord  around  the  foetus.     The  ends  of  this 


Fig.  72. — Bone-Forceps. 

cord  are  brought  out  of  the  vagina  through  a  cylindrical  specu- 
lum, and  then,  by  traction  on  the  ends  of  the  cord,  the  foetal 
trunk  may  usually  be  sawn  through.  This  failing,  the  sole 
alternative  is  to  cut  through  the  spinal  column  by  the  scissors. 
The  name  of  spondylotomy  has  been  applied  to  these  proced- 
ures. Such  an  amount  of  traumatism  is  thus  entailed  that  we 
question  if,  where  the  conjugate  is  diminished  below  two  and 
three-fourths  inches,  it  be  not  preferable  to  enlarge  the  pelvic 
diameters  by  symphysiotomy  in  order  to  obtain  greater  working 
space. 

Where  the  neck  of  the  foetus  is  accessible  decapitation  is 


Fig.  73.— Crochet  and  Blunt  Hook. 


the  operation  of  choice.  A  number  of  instruments,  compli- 
cated to  a  greater  or  less  degree,  have  been  devised  for  the  per- 
formance of  decapitation.  The  simplest  of  all  is  the  Braun 
hook  or  decollator.  This  hook  can  be  used  in  every  instance 
where  the  more  complicated  apparatus  can ;  it  is  serviceable 
where  the  latter  is  not,  for  the  reason  that  if  there  is  not  space 


158  OBSTETRIC     SURGERY. 

enough  to  pass  the  decollator  it  is  likewise  impossible  to  adapt 
the  chain-saw  ;  it  is  readily  rendered  aseptic  and  is  less  likely  to 
injure  the  maternal  parts  than  any  of  the  other  devices. 

In  an  emergency,  where  the  Braun  instrument  is  not  at 
hand,  a  stout  sterilized  cord  may  be  carried  around  tlie  foetal 
neck  by  means  of  a  sterilized  elastic  catheter ;  the  ends  of  the 
cord  are  carried  through  a  cyhndrical  speculum  out  of  the 
vagina,  and  a  see-saw  motion  associated  with  traction-  will  sever 
the  head  from  the  trunk.  Whenever  possible,  however,  the 
Braun  hook  is  to  be  preferred,  and  the  steps  of  the  operation  are 
as  follow  :  The  bladder  is  to  be  emptied.  The  genital  tract, 
the  hands  of  the  operator  and  of  his  assistants  having  been  care- 
fully asepticized,   the  foetal  arm  is  brought  down  out  of  the 


Fig.  71.— Braun's  Hook  or  Decollator. 

vagina  and  handed  to  an  assistant,  who,  through  the  exerted 
traction,  steadies  the  fcetal  neck  at  the  brim  and  makes  it  more 
accessible.  It  is  desirable  to  exert  traction  on  this  arm  by 
means  of  a  tape  or  towel  tied  to  it,  otherwise  the  assistant  will 
be  in  the  way  of  the  operator. 

The  aim  of  the  operator  is  to  pass  the  hook  around  the 
neck  of  the  foetus,  and  this  is  accomplished  as  follows:  Inserting 
two  fingers  of  tlie  right  or  the  left  hand  (according  as  the  foetal 
head  occupies  the  left  or  the  right  half  of  the  pelvis)  into  the 
vagina,  the  hook  is  passed  flat  along  these  fingers  until  the  neck 
of  the  foetus  is  reached.  The  point  of  the  hook  is  then  guided 
around  the  neck  by  these  fingers  from  above  downward,  in 
order  to  lessen  the  risk  of  injuring  the  bladder.     (Plate  XV.) 


EMBRYOTOMY.  159 

Firm  traction  is  tlien  made  on  the  hook  in  order  to  assure  a 
thorough  hold  on  the  neck,  the  fingers  remaining  in  place  so 
as  to  certify  that  the  point  of  the  hook  is  not  injuring  the 
maternal  parts.  The  hook  is  rotated,  traction  being  maintained 
until  the  neck  is  felt  to  yield  through  the  breaking  of  the 
spinal  column.  As  a  rule,  the  soft  parts  also  are  thus  severed, 
and  the  hook  is  removed  along  the  fingers.  If  the  hook  has 
failed  to  sever  completely  the  muscular  attachments,  the  scissors, 
guided  along  the  fingers,  must  be  utilized. 


Fig.  75.— Delivery  of  Trunk  after  Section  of  Head. 

The  neck  of  the  foetus  having  been  severed,  traction  on  the 
prolapsed  foetal  arm  will  ordinarily  serve  to  deliver  the  trunk, 
the  foetal  head  slipping  upward.  The  next  step  is  to  remove 
the  head. 

If  the  indication  for  decapitation  has  been  an  impacted 
transverse  position  of  the  dead  foetus,  in  a  pelvis  where  there 
exists  no  special  disproportion  between  the  pelvis  and  the 
foetus,  the  forceps  will  answer  for  extraction.  The  head  being 
steadied    at    the    pelvic   brim   by  an   assistant,   the    forceps    is 


160 


OBSTETRIC     SURGERY. 


applied  in  the  usual  manner,  and  delivery  is  effected  under  the 
rules  applicable  to  the  forceps  operation. 

Where,  however,  there  exists  dystocia  due  to  contracted 
pelvis  or  to  large  foetus,  the  manipulations  become  more  difficult 
according  to  the  degree  of  dystocia.  The  method  of  inserting 
the  blunt  hook  into  the  cranium  through  the  foramen  magnum 
and  delivering  by  traction  has  been  advocated,  but  should  be 
rejected  owing  to  the  risk  of  the  hook  slipping  and  injuring 
the  maternal  parts.     The  preferable  method  is  the  following : 


Fig.  76.— Locked  Twins. 

If  the  head  can  be  fixed  at  the  brim  with  the  foramen  magnum 
presenting  toward  the  vagina,  then  excerebration  by  the  metal 
sound  and  extraction  by  the  cranioclast  or  the  cephalotribe  is 
advisable.  If  the  head  cannot  be  so  fixed,  then  perforation  by 
the  trephine  or  the  scissors-perforator  is  demanded,  followed  by 
extraction  by  the  cranioclast  or  the  cephalotribe.  The  risk  to 
the  maternal  parts  is  here  great,  owing  to  the  fact  that  the 
point  of  impact  of  the  trephine  or  scissors  can  rarely  be  at  a 
right  angle,  and  there  is,  therefore,  great  danger  of  the  instru- 


EMBRYOTOMY.  161 

ments  slipping.  If  the  pelvis  be  large  enough  to  permit  of  its 
introduction,  Tarnier's  basiotribe  will  answer  admirably. 

The  uterus  having  been  emptied,  a  2-per-cent.  cueolin  or  a 
1  to  8000  bichloride  douche  should  be  administered,  and  lesion 
of  the  genital  tract  be  repaired  us  completely  as  is  possible. 

Aside  from  impacted  transverse  presentation,  decapitation 
may  be  called  for  in  case  of  locked  twins. 

The  trunk  of  one  foetus  having  been  born,  and  it  being 
found  impossible  by  manual  and  postural  treatment  to  decom- 
pose the  wedge  formed  by  the  foetal  heads,  the  only  possible 
resource  is  the  sacrificing  of  the  first  foetus — in  case  it  be  not 
already  dead — in  order  to  give  the  second  foetus  cliance  of  life ; 
for  it  is  tlie  first  foetus,  the  trunk  of  Avhich  is  born,  whose  life 
is  most  endangered.  The  steps  of  the  operation  do  not  differ 
from  those  just  stated. 

Prognosis  of  Embryotomy. 

It  is  not  possible  to  state  specifically  the  death-rate  from 
embryotomy.  The  statistical  data  at  disposal  are  worthless, 
because  of  the  fact  that  many  of  the  records  include  operations 
performed  before  the  stringency  of  asepsis  was  recognized,  and, 
further,  because  the  operation,  except  under  absolute  indication, 
has  rarely  been  one  of  election.  It  is  a  significant  fact  that  the 
mortality  following  embryotomy  is  higher  in  private  than  in 
hospital  practice.  The  reason  is  that  in  the  former  practice  the 
temptation  is  to  test  the  methods  of  delivery  by  forceps  and 
version  before  resorting  to  embryotomy ;  often  because  accurate 
mensuration  of  the  pelvis  having  been  neglected,  the  prac- 
titioner is  unaware  of  the  cause  of  the  dystocia  till  his  eyes  are 
opened  by  the  fact  that  the  methods  of  delivery  with  which  he 
is  most  familiar  are  of  no  avail.  Embryotomy  is  then  resorted 
to  on  an  exhausted  woman  with  genital  tract  already  damaged, 
to  a  greater  or  less  degree,  by  the  futile  efforts  at  delivery  by 
methods  which  the  mechanical  problem  forbid.  Deliberate 
election  of  embryotomy,  on  the  other  hand,  is  more  likely  to  be 


162  OBSTETRIC     SURGERY. 

the  rule  in  hospitals,  and,  therefore,  the  mortality  is  lower. 
Further  still,  the  mortality  depends  on  the  indication  for  the 
operation  selected.  Where  the  dystocia  is  not  extreme  and  the 
operation,  therefore,  not  a  difficult  one,  the  sole  risk  entailed  by 
embryotomy  is  sepsis.  In  the  higher  degrees  of  dystocia,  par- 
ticularly where  evisceration  is  called  for,  the  mortality  must 
always  remain  relatively  high  owing  to  the  lesions  which,  even 
in  the  hands  of  the  most  expert,  the  maternal  parts  are  likely 
to  incur. 

Minor  lesions,  such  as  lacerations  of  the  cervix  or  of  the 
pelvic  floor,  if  repaired  at  once  and  aseptically,  are  not  likely  to 
enter  as  complications  of  the  puerperal  state.  Neither  are 
fistulse,  if  the  result  of  direct  traumatism  and  not  of  sloughing 
following  prolonged  pressure.  The  major  risk  the  woman  runs 
is  rupture  of  the  uterus, — a  not  unlikely  accident  where  embry- 
otomy is  demanded  in  a  justo-minor  pelvis  of  high  grade 
through  an  undilated  cervix.  Whilst,  indeed,  embryotomy 
may  prove  a  very  simple  operation,  it  may  also  become  the 
most  difficult  of  all  the  obstetric  operations.  For  this  reason, 
when  the  child  is  alive,  it  has  become  the  custom  in  hospitals 
to  weigh  carefully  the  chances  in  the  boundary-line  cases  of 
Csesarean  section  and  of  embryotomy.  It  becomes  a  question 
not,  as  is  often  erroneously  argued,  of  the  greater  value  of 
one  life  over  another ;  it  becomes  a  question  of  the  deliberate, 
scientific  election  of  that  operation  which  subjects  the  woman 
to  the  least  risk.  There  is  no  doubt  but  that  -difficult  embry- 
otomy, in  the  hands  of  the  non-expert,  subjects  the  woman  to 
greater  risk  than  does  the  Csesarean  section,  provided  always 
that  he  is  familiar  with  the  simple  technique  of  the  latter  opera- 
tion, as  he  should  be,  if  competent  to  attend  the  lying-in  woman 
at  all. 


CHAPTER    yill. 
THE    SURGERY  OF   THE  PUERPERIUM. 

The  puerperal  state  begins  with  the  expulsion  of  the  pla- 
centa, which  event  terminates  the  third  stage  of  labor.  In  case 
surgical  interference  has  been  required  during  the  course  of 
labor,  the  genital  tract  has  likely  enough  suffered  certain  lesions 
which  it  becomes  tire  duty  of  the  physician  to  repair.  As  a 
rule,  the  surgery  requisite  may  be  denominated  minor,  with  the 
exception  of  one  complication, — rupture  of  the  uterus. 

In  the  event  of  the  labor  or  the  surgical  interference  not 
having  been  conducted  aseptically,  there  will  develop,  during  the 
course  of  the  puerperal  state,  a  number  of  complications,  which 
may  also  require  surgical  intervention,  and,  as  a  rule,  this  sur- 
gery is  of  a  major  nature. 

The  operations,  then,  which  we  are  called  upon  to  consider 
depend  either  on  traumatism,  avoidable  or  unavoidable,  or  on 
sepsis,  which,  from  the  modern  stand-point,  must  be  loolced 
upon  as  almost  always  avoidable. 

The  operations  resulting  from  traumatism  are  the  follow- 
ing:  1.  Laceration  of  the  cervix.  2.  Laceration  of  the  pelvic 
floor.     3.  Fistulse.     4.  Rupture  of  the  uterus. 

The  affections  depending  on  septic  infection  which  may 
demand  surgical  interference  are:  1.  Endometritis  and  metritis. 
2.  Pelvic  abscess.     3.  Peritonitis.     4.  Mastitis. 

Immediate  Repair  of  the  Lacerated  Cervix. 

It  is  only  of  late  years  that  it  has  been  considered  desirable 
to  attempt  the  immediate  repair  of  the  lacerated  cervix.  The 
objections  to  the  operation  have  been  the  problematical  result 
as  regards  primary  union  and,  further,  the  belief  that  it  was 
impossible  to  resort  to  the  operation  without  the  presence 
of  a  number  of  assistants.     There  are  now  a  sufficient  number 

(163) 


164  OBSTETRIC     SURGERY. 

of  cases  recorded  to  warrant  the  assertion  that  primary  union 
may  usually  be  expected,  and  if  the  technique  we  proceed  to 
describe  be  followed  skilled  assistants  are  not  necessary.  On 
the  other  hand,  the  primary  operation  shuts  oiF  one  of  the 
avenues  of  sepsis,  and  removes  at  once  one  of  the  most  frequent 
causes  of  subinvolution,  as  well  as,  in  case  of  union,  relieves 
the  patient  of  the  necessity  of  the  secondary  operation. 

The  immediate  operation  is  either  one  of  election  or  one 
of  strict  necessity.  It  becomes  one  of  necessity  when,  either 
after  spontaneous  labor  or  after  operative  interference,  profuse 
haemorrhage  occurs  and  continues,  which,  on  investigation,  is 
found  to  be  due  to  a  cervical  tear  involving  a  circular  artery. 
Here  the  only  other  resource  is  tamponing  the  vagina,  which  is 
unscientific  as  well  as  often  nugatory.  The  operation  becomes 
one  of  election  in  the  lesser  degrees  of  laceration.  Unquestion- 
ably many  such  lacerations  heal  spontaneously,  probably  the 
vast  majority  if  the  course  of  the  puerperium  is  aseptic.  Still, 
we  question  if,  where  the  laceration  exceeds  what  may  be  termed 
tiie  first  degree,  the  patient  has  not  the  right  to  expect  her  phy- 
sician to  leave  her  in  the  best  possible  condition,  in  order  to 
save  her  from  the  grasp  of  the  gynaecologist  later. 

In  case  the  operation  is  called  for  on  account  of  laceration 
involving  the  circular  artery,  there  exists  no  contra-indication. 
The  immediate  safety  of  the  woman  demands  it.  There  are 
contra-indication s  to  tlie  performance  of  the  operation  in  the 
presence  of  the  lesser  grades  of  laceration.  If  the  woman  is 
exhausted  from  prolonged  labor,  or  if,  owing  to  post-partum 
haemorrhage,  it  has  become  necessary  to  use  the  uterine  tam- 
ponade, then  resort  to  the  operation  is  either  inadvisable  or 
impracticable. 

The  instruments  requisite  for  the  performance  of  the 
operation  are  the  following:  A  strong  vulsellum  forceps,  a 
needle-holder,  and  a  few  large  curved  needles,  preferably  the 
Hagedorn.  The  preferable  suture  material  is  silk-worm  gut. 
Catgut  is  unreliable,  since  it  is  apt  to  dissolve  too  soon  and. 


THE  SURGERY  OF  THE  PUERPERIUM.  165 

furthermore,  because  the  knot  is  apt  to  shp.  The  silk-worm  gut 
is  readily  sterilized  by  boiling  for  a  few  minutes,  and  may  be  left 
in  situ  for  weeks,  as  may  be  requisite,  if,  at  the  same  time,  it  is 
necessary  to  repair  the  pelvic  floor.  A  speculum  is  not  strictly 
requisite,  since,  according  to  the  technique  about  to  be  de- 
scribed, the  operation  is  performed  without  one.  The  main 
advantage  in  dispensing  with  a  speculum  is  that  thus  an  assist- 
ant to  hold  it  is  not  required.  If  the  operator  happen  to  have 
an  Edebohl  speculum  with  him,  however,  the  counter-weight 
may  be  obtained  by  means  of  a  fiat-iron,  which  is  to  be  found 
in  every  household. 

The  steps  of  the  operation  are  the  following:  The  Avoman 
is  brought  to  the  edge  of  the  bed ;  the  bladder  is  emptied ; 
anaesthesia  is  only  requisite  in  case  the  woman  is  excessively 
nervous.  If  the  requisite  assistants — two  in  number — are  pres- 
ent, each  may  support  a  leg ;  but,  in  the  event  of  these  assist- 
ants not  being  present,  the  physician  may  use  a  sheet  as  a 
leg-holder  by  passing  it  around  the  knees  and  tying  it  to  the 
patient's  arms.  The  requisite  instruments,  having  been  steril- 
ized by  boiling,  are  placed  handy  to  the  operator's  right  hand, 
a  lighted  candle  or  lamp,  in  case  the  gaslight  is  not  sufficient, 
being  held  by  the  nurse  or  by  some  relative  so  as  to  illuminate 
the  field  of  operation  thoroughly. 

The  operator  seizes  the  cervical  lips  firmly  with  the  double 
tenaculum,  and  pulls  the  uterus  downward  until  the  cervix  is 
at  the  ostium  vaginae.  The  object  of  this  traction  is  two- 
fold: In  the  first  place,  the  laceration  is  thus  made  accessible 
for  operation,  being  performed  under  the  guidance  of  the  eye, 
and,  in  the  second  place,  when  the  uterus  is  thus  pulled  down- 
ward, it  is  a  well-known  fact  that  haemorrhage  from  the  organ 
is,  in  a  measure,  checked.  For  this  reason  the  technique  de- 
scribed is  preferable  to  that  which  entails  operating  through 
the  Sims  speculum,  when  the  haemorrhagic  flow  which  always 
exists  after  the  completion  of  labor  renders  the  operation  diffi- 
cult by  interfering  with  the  field  of  vision.     The  next  step  is  to 


166 


OBSTETRIC     SURGERY. 


pass  the  first  and  the  most  difficult  of  the  stitches,  which,  once 
in  place,  gives  the  operator  full  control.  A  Hagedorn  needle 
threaded  with  silk-worm  gut  is  passed  deeply,  at  the  angle 
through  the  posterior  cervical  lip.  under  the  lacerated  surface, 
emerging  in  the  canal.  It  is  re-inserted  into  the  anterior  lip  at 
the  canal,  and  emerges  at  the  angle  of  the  tear  in  the  anterior 
lip.  The  remaining  stitches  are  inserted  in  a  similar  manner, 
first  on  the  one  side,  and  next  on  the  other,  until  the  raw  sur- 
faces of  each  lip  have  been   approximated.     The  sutures  are 


Fig.  I  (.—Sutures  Inserted  on  One  Side  of  a  Lacerated  Cervix. 


next  tied.  It  is  important  to  remember  that  it  is  essential  to 
tie  the  stitches  tighter  after  the  primary  operation  than  after 
the  secondary,  when  the  aim  is  simply  to  bring  tlie  denuded 
surfaces  in  apposition.  After  delivery,  the  cervix  is  always 
osdematous  to  a  greater  or  less  degree,  and,  if  the  stitches  be 
not  tied  tightly  then,  in  the  course  of  a  few  days,  when  the 
oedema  disappears,  the  stitches  will  necessarily  be  slack  and 
deep  union  by  first  intention  is  unlikely.  It  is  to  the  neglect 
of  this  precaution,  we  believe,  that  failure  after  the  primary 
operation  may  often  be  traced. 


THE  SURGERY  OF  THE  PUERPERIUM.  167 

The  sutures  having  beeu  tied,  the  vulsellum  forceps  is 
removed  and  a  hot  2-per-cent.  creolin  douche  is  administered. 
The  average  time  requisite  for  this  operation  is  ten  minutes. 
In  case  of  failure  in  obtaining  union,  the  woman's  condition  is 
none  the  worse  for  the  attempt  made  to  leave  her  in  the  best 
possible  condition,  whilst,  as  already  stated,  if  union  do  occur, 
the  woman  is  spared  many  of  the  ills  which  a  lacerated  cervix 
sooner  or  later  entails.  There  is  a  further  phase  of  this  question 
which  it  is  well  to  dwell  upon.  If  the  immediate  operation  be 
not  performed  in  case  of  deep  cervical  laceration,  dense  cica- 
tricial tissue  inevitably  forms,  so  that  when  the  secondary  opera- 
tion is  called  for  there  is  not  alone  much  more  difficulty  in 
performance,  but  it  may  even,  in  the  opinion  of  many,  become 
not  a  question  of  mere  repair  of  a  laceration,  but  one  of  ampu- 
tation,— a  more  radical  operation.  AVe  believe  that  before  long 
it  will  be  recognized  as  desirable  to  perform  immediate  trache- 
lorrhaphy, as  it  is  to-day  considered  a  sign  of  incompetency  if 
repair  of  the  pelvic  floor  is  not  attended  to  immediately,  in  the 
absence  of  contra-indication. 

The  stitches  in  the  cervix  may  be  left  in  situ  from  ten  days 
to  a  number  of  weeks,  according  to  the  necessities  of  the  case. 
The  longer  interval  is  requisite  where  it  has  also  been  necessary 
to  operate  on  the  pelvic  floor.  If  the  stitches  are  aseptic,  as 
they  should  be,  when  introduced,  they  can  give  rise  to  no  possi- 
ble trouble  during  the  puerperal  state.  The  assumption  that 
they  may  interfere  with  drainage  of  the  lochia  is  untenable, 
since  the  operation  simply  restores  the  cervix  to  the  shape  it  has 
where  laceration  has  not  occurred.  It  goes  without  saying  that 
we  presuppose  that  requisite  care  has  been  taken  not  to  sew  up 
the  cervical  canal. 

Immediate  Perineorrhaphy. 

The  conscientious  physician  aims  to  leave  his  patient,  after 
confinement,  with  the  pelvic  floor  in  as  sound  a  condition  as  art 
can  make  it,  in  the  event  of  its  having  been  lacerated  during 


168  OBSTETRIC     SURGERY. 

the  process  of  delivery-  There  is  little  need  at  the  present  day 
to  dwell  on  the  untoward  sequelae  which  inevitably  follow  in 
the  train  of  unrepaired  lesion  of  the  pelvic  floor.  The  laity,  as 
well  as  physicians  in  general,  recognize  the  necessity  of  the 
primary  operation, — so  much  so,  indeed,  that  the  former  con- 
sider their  medical  attendant  blameworthy  who  has  failed  to 
recognize  a  lesion,  and  thus  neglected  to  repair  it.  The  student 
need  not  have  the  fear  that,  if  the  lesion  occur,  it  will  be  laid 
to  his  lack  of  skill.  The  practitioner  who  claims  that,  in  an 
extensive  practice,  he  has  never  seen  a  lacerated  perineum  has 
become  to-day  a  vara  avis  in  the  light  of  the  recorded  experi- 
ence from  hospitals  which  certify  to  the  necessarily  frequent 
occurrence  of  lesion  even  in  the  hands  of  the  most  expert. 
The  proper  spirit  to-day  is  to  fear  the  blame  which  deservedly 
attaches  itself  to  the  attendant  who  neglects  the  performance  of 
the  primary  operation  whenever  the  conditions  contra-indicating 
are  absent. 

The  routine  practice,  after  the  completion  of  the  third 
stage  of  labor,  should  be  to  investigate  by  sight,  as  well  as  by 
touch,  the  pelvic  floor.  There  may  be  no  apparent  lesion 
externally,  and  yet,  on  separation  of  the  labia,  the  most  dan- 
gerous of  all  lesions,  as  regards  its  after-consequences,  will  be 
detected.  It  is  now  firmly  established  that  the  mere  external 
tears  are  of  no  consequence  beyond  opening  an  avenue  for  the 
entrance  of  germs.  It  is  the  tears  which  involve  the  muscles 
and  fascia  of  the  pelvic  floor  which  entail  ultimately  rectocele 
and  cystocele,  with  their  sequelae.  Too  much  stress,  therefore, 
cannot  be  laid  on  the  necessity  of  separating  the  labia  and 
examining  the  pelvic  floor. 

The  sole  contra-indication  to  the  immediate  operation  is 
exhaustion  of  the  woman  to  such  a  degree,  from  prolonged 
labor  or  from  post-partum  haemorrhage,  as  to  call  for  absolute 
and  immediate  rest  on  her  part.  Of  course,  where,  owing  to 
post-partum  haemorrhage,  it  has  been  necessary  to  resort  to  the 
gauze  tamponade  of  the  genital  tract,  the  operation  cannot  be 


THE  SURGERY  OF  THE  PUERPERIUM.  169 

performed.  Where  the  lesion,  at  best,  requires  but  a  few 
stitches,  anaesthesia  is  not  requisite,  since  the  sensibility  of  the 
pelvic  floor  has  been  largely  diminished  from  the  pressure  asso- 
ciated with  delivery.  But,  if  the  tear  be  one  of  a  major  degree, 
anaesthesia  is  desirable  in  order  to  enable  the  attendant  to  per- 
form the  operation  with  the  requisite  care  as  well  as  in  order  to 
save  the  woman  unnecessary  pain. 

The  instruments  requisite  are  the  following  :  A  pair  of 
scissors,  a  needle-holder,  a  few  curved  needles  (preferably  the 
Hagedorn).  Material  for  suture  will  differ  according  to  indi- 
vidual preference,  but  the  silk-worm  gut  possesses  all  the  advan- 
tages of  silver  wire  or  catgut,  and  has  none  of  the  disadvantages 
of  the  latter.  Where  the  tear  is  chiefly  internal,  catgut,  if  its 
asepticism  can  be  depended  upon,  answers  admirably,  since  it  is 
possible  to  use  it  as  a  running  suture  ;  but  even  then  it  may  dis- 
solve before  deep  union  is  secured,  or,  notwithstanding  the  pre- 
cautions taken,  it  may  prove  the  source  of  local  sepsis.  As  for 
silver  wire,  it  possesses  no  advantages  for  the  primary  operation 
over  silk-worm  gut,  and  requires  infinitely  more  time  for  adjust- 
ment as  well  as  more  instruments.  Silk-worm  gut  is  readily 
sterilized  by  boiling,  and,  if  aseptic,  it  may  be  left  in  situ  for  an 
indefinite  time. 

The  method  of  operating  will  be  modified  according  to  the 
character  of  the  laceration.  The  most  complex  operation,  of 
course,  is  demanded  where  the  laceration  extends  through  the 
sphincter  ani,  to  a  greater  or  a  less  extent,  up  the  rectal  wall. 
In  the  lesser  grades  the  suturing  usually  will  be  almost  entirely 
Avithin  the  vagina.  Before  proceeding  to  operate  the  physician 
should  make  a  careful  examination  in  order  to  determine  the 
manner  after  which  the  pelvic  floor  has  been  injured,  in  order  to 
secure  deep  union  and  proper  approximation  of  the  fascia  and 
muscles.  The  ancient  method  of  simply  passing  the  sutures  in 
at  one  side  and  out  at  the  other  will  not  stand  the  critical  test 
of  modern  methods,  for  the  day  has  gone  by  when  securing  a 
skin  perineum  is  deemed  sufficient.     The  parts  operated  upon 


170  OBSTETRIC     SURGERY. 

must  i]ot  alone  look  well,  but  must  also  subserve  their  intended 
purpose  well. 

Where  the  laceration  has  not  extended  through  the 
sphincter  of  the  anus  the  steps  of  the  operation  are  as  follow : 
The  woman  is  brought  to  the  edge  of  the  bed,  the  legs  are  flexed 
on  the  abdomen  and  are  held  there  by  the  nurse,  or,  if  she  is 
needed  for  other  purposes,  a  sheet  may  be  passed  under  the 
knees  and  each  end  tied  to  the  patient's  arms.  As  a  rule,  ex- 
cept in  the  minor  degrees  of  laceration,  anaesthesia  is  requisite. 
In  order  to  avoid  sponging,  the  field  of  operation  may  be  irri- 
gated to  advantage  by  a  weak  solution  of  bichloride.  Creolin 
is  objectionable  for  irrigating  purposes,  since,  owing  to  its  color, 
it  interferes  with  a  good  view  of  the  field  of  operation.  An 
assistant  or  the  nurse,  Avith  aseptic  hands,  separates  the  labia  so 
that  the  operator  may  determine  the  extent  of  the  laceration. 
AYith  the  scissors  jagged  ends  of  tissue  are  cut  off",  thus  securing 
an  even  surface  for  union.  If  the  laceration  has  extended 
chiefiy  into  one  sulcus,  as  is  not  infrequently  the  case  in  the 
lesser  degrees  of  lesion,  a  running  catgut  suture  may  be  used 
to  advantage.  The  needle  is  inserted  at  the  apex  of  the  tear, 
deeply,  so  as  to  secure  as  much  of  the  divided  fascia  as  possible, 
and  the  gut  is  tied.  The  over-and-over  stitch  is  now  rapidly 
taken,  the  needle  on  each  occasion  it  is  inserted  being  made  to 
enter  deeply,  until  the  external  end  of  the  laceration  has  been 
reached,  when  it  is  tied.  Occasionally  the  tear  involves  both 
sulci,  in  which  event  the  process  is  repeated  on  the  other  side. 
In  order  to  see  well,  the  upper  vagina  is  tamponed  with  steril- 
ized gauze,  which  prevents  the  trickling  of  the  uterine  discharges. 

In  general,  however,  Hegar's  method  of  operating  (mod- 
ified) will  give  the  most  satisfactory  result,  even  though  its 
performance  takes  more  time  than  that  which  we  have  just 
described. 

The  method  is  peculiarly  applicable  to  the  vast  majority 
of  lacerations,  since  these  begin  in  the  median  line  and  extend 
laterally.     The  suturing  is  almost  entirely  internal,  and  appvox- 


THE  SURGERY  OF  THE  PUERPERIUM.  171 

imates  accurately  the  divided  ends  of  the  muscles  and  fascia, 
the  aim  which  is  essential  in  order  to  properly  repair  the  lesion. 
The  needle  is  inserted  at  the  margin  of  the  tear  near  its 
apex,  and  passed  deeply  around  to  the  opposite  side.  Similar 
sutures  are  inserted  at  an  interval  of  about  a  quarter  of  an  inch 
apart,  till  the  tear  has  been  approximated  down  to  the  carun- 
culse  myrtiformes.  The  sutures  are  then  tied  and  cut  short. 
The  superficial  tear  remaining  is  brought  together  by  two  or 




■"•~~>^_^ 

^,^^''" 

•<:' 

-        ~~~~~~-- 

B-"" 

"^"^ 

Fig.  78.— Insertion  of  Sutures.     (After  Hegar.) 
A,  A,  intra-vaginal  sutures ;  b,  b,  external  sutures. 

more  sutures.  Silk-worm  gut  answers  admirably,  and,  if  need 
be,  a  few  interrupted  sutures  of  catgut  may  be  inserted.  These 
sutures,  if,  aseptic,  may  remain  in  place  for  a  week  or  ten  days. 
If  there  exist  much  oedema  of  the  pelvic  floor,  the  result  of  pro- 
tracted labor,  the  precaution  must  be  taken  to  tie  the  sutures  a 
trifle  tighter  than  is  the  rule  for  plastic  work ;  otherwise,  on  the 
disappearance  of  the  oedema,  the  sutures  will  be  relaxed  and 
deep  union  will  not  be  secured. 


172 


OBSTETRIC     SURGERY. 


Where  the  laceration  has  been  so  extensive  as  to  involve" 
not  only  the  pelvic  floor,  but  also  the  sphincter  ani  and  the 
recto- vaginal  septum,  there  is  all  the  more  call  for  the  imme- 
diate operation,  and  the  procedure  is  proportionately  more  com- 
plicated. It  is  above  all  things  important  to  bring  together  the 
torn  ends  of  the  sphincter  ani,  for  otherwise  the  woman  will 
suifer  from  incontinence  of  faeces  to  a  greater  or  less  degree,  and 
will,  in  consequence,  inevitably  require  the  secondary  operation. 
In  this  operation  we  still  prefer  the  silk-worm  gut  for  suture 


Fig.  79. — Laceration  tliroiigli  the  Sphincter.    Spliincter  Sutures  in  Place. 

purposes.  It  holds  just  as  well  as  silver  wire,  and  is  a  source 
of  less  discomfort  to  the  woman.  The  iirst  stitches  to  be  inserted 
are  the  rectal.  The  needle  is  inserted  below  the  margin  of  the 
tear  and  is  carried  deeply  outward  so  as  to  grasp  the  torn  ends 
of  the  sphincter.  It  circles  around  the  recto-vaginal  septum 
and  emerges  at  the  opposite  side,  grasping  the  other  end  of  the 
sphincter.  As  a  rule,  two  sutures  are  requisite  to  secure  the 
sphincter  muscle,  and  when  inserted  these  may  be  tied.  The 
laceration  of  the  pelvic  floor  is  then  repaired  according  to  the 
method  just  described. 


THE  SURGERY  OF  THE  PUERPERIUM.  173 

Exceptionally,  the  laceration  occurs  directly  through  the 
perineum,  giving  rise  to  what  is  termed  central  laceration.  In 
case  of  this  accident,  the  method  of  procedure  consists  in 
converting  the  central  laceration  into  a  complete,  by  slitting 
through  the  bridge  of  tissue  remaining  between  the  laceration 
and  the  pelvic  floor,  and  then  repairing  the  lesion  after  the 
method  described. 

If  the  steps  of  the  operations  just  described  are  aseptic, 
the  management  of  the  puerperal  state  does  not  differ  materially 
from  the  normal.  It  is  unnecessary  to  administer  vaginal 
douches,  since  the  non-septic  lochia  will  not  interfere  with 
union.  The  old-time  rule  of  keeping  the  bowels  constipated  is 
not  deemed  good  practice  to-day.  The  comfort  of  the  puerpera 
demands  that  the  intestinal  canal  should  not  be  allowed  to 
become  clogged,  and  the  perineal  tear  is  more  likely  to  heal 
from  the  depths  if  we  take  precautions  to  prevent  hardened 
fsecal  matter  from  collecting  in  the  rectal  cul-de-sac.  It  is  a 
good  rule,  therefore,  to  order  a  saline  laxative  within  twenty- 
four  hours  after  delivery,  and  thereafter  every  day,  so  as  to 
secure  copious  liquid  evacuations.  The  coaptated  surface  may 
be  kept  powdered  with  iodoform,  aristol,  or  boracic  acid,  and  the 
nurse  should  be  strictly  enjoined  to  exercise  scrupulous  cleanli- 
ness of  the  external  genitals.  For  the  first  few  days  the  woman 
had  better  be  catheterized,  or  else,  and  this  we  prefer,  when  she 
passes  water  it  should  be  under  the  administration  of  a  weak 
creolin  or  bichloride  douche.  It  is  very  questionable  if  the 
normal  urine  will  interfere  at  all  with  primary  union. 

In  the  event  of  the  primary  operation  proving  a  failure, 
the  woman  should  be  advised  to  submit  to  the  secondary  opera- 
tion as  early  as  may  be,  for  the  longer  she  waits  the  greater  the 
cicatricial  tissue,  and  the  more  aggravated  the  rectocele  and 
possibly  the  cystocele  which  will  form. 


174 


OBSTETRIC     SURGERY. 


Fistula. 
Only  exceptionally,  nowadays,  are  fistulse  of  the  genital 
tract  encountered,  for  the  reason  that  their  chief  causes  are  not 
allowed  to  act.  Protracted  labor  was  formerly  responsible  for 
the  majority  of  fistulse.  Traumatism,  except  in  the  presence  of 
a  major  degree  of  pelvic  contraction  when  surgical  interference 


Fig.  80.— Repair  of  a  Vesico-Vaginal  Fistula. 


was  demanded,  was  rarely  a  causative  factor.  It  is  only  when 
a  fistula  forms  as  the  result  of  surgical  interference  that  the 
])hysician,  in  the  capacity  of  accoucheur,  will  be  called  upon 
to  perform  immediate  operation.  The  fistulse  which  result  from 
prolonged  pressure  of  the  foetal  presenting  part  on  the  pelvic 
floor  rarely  make  themselves   evident   until  a  number  of  days 


THE  SURGERY  OF  THE  PUERPERIUM. 


175 


after  labor.  The  process  is  purely  one  of  sloughing  in  these 
latter  instances.  Of  course,  here,  as  well,  it  is  eminently  neces- 
sary to  take  measures  for  repair  of  the  lesion  as  soon  as  the  con- 
dition of  the  woman  will  allow,  since  the  formation  of  extensive 
cicatrices  will  render  the  operation  most  difficult  and  the  result 
problematical. 


Fig.  81.— Simon's  Specula. 


In  vieAv  of  the  difficulty  of  the  secondary  operation  for 
fistula,  it  may  at  first  sight  seem  useless  to  attempt  repair  im- 
mediately after  delivery.  When  we  remember,  however,  the 
untoward  sequelae  of  both  urinary  and  fsecal  fistulse,  and  the 
re[)eated  attempts  which  are  often  requisite  before  union  can  be 
secured  after  the  secondary  operation,  there  is  little  need  of 
dwelling  further  on  the  desirability  of  aiming  at  primary  union. 


176  OBSTETRIC     SURGERY. 

The  main  reason  why  the  primary  operation  is  difficult  is  the 
impossibility  of  placing  the  recently-delivered  puerpera  in  the 
best  position  for  performing  the  operation,  particularly  Avhen  the 
fistula  affects  the  bladder.  This,  indeed,  will  prove  a  distinct 
contra-indication  when  the  fistula  is  seated  high  up  ;  but  when 
the  lesion  is  low  enough  down  to  enable  the  physician  to  bring 
it  into  view  without  placing  the  woman  in  the  genu-pectoral 
position,  the  attempt  at  primary  repair  should  always  be  made. 
Kectal  fistulse  may  ordinarily  be  exposed  with  less  difficulty  than 
the  vesical. 

The  steps  of  the  operation  either  for  rectal  or  vesical  fistulee 
do  not  differ  from  those  requisite  for  the  performance  of  the  sec- 
ondary operation.  To  prevent  the  lochia  from  trickling  down 
and  interfering  with  the  field  of  vision,  it  suffices  to  pack  the 
upper  portion  of  the  vagina  with  sterilized  gauze.  Since  there 
is  no  cicatricial  tissue  and,  consequently,  no  special  tension  to 
he  overcome,  silk-worm  gut  will  answer  for  suture  purposes. 

If  the  fistula  is  at  all  accessible  with  the  woman  in  the 
dorsal  position,  the  edges  are  made  tense  by  traction  with  a 
tenaculum,  and  the  sutures  are  inserted  one  after  another  from 
one  edge  of  the  fistula  out  at  the  other.  The  same  care  is 
requisite,  as  in  the  secondary  operation,  not  to  pass  the  stitches 
through  the  vesical  wall.  Coaptation  of  the  torn  edges  must  be 
accurate  and  the  stitches  must  be  tied  more  tightly  than  in  the 
secondary  operation,  because  when  any  oedema  present  has 
disappeared  the  stitches  will  otherwise  become  relaxed. 

The  after-treatment  will  not  differ  from  that  of  the  normal 
puerperium.  The  bowels  should  be  kept  fluid,  and  where  the 
lesion  has  involved  the  bladder  the  catheter  should  be  passed  at 
least  every  six  hours  for  five  to  six  days.  As  is  the  rule  for  the 
puerperal  state,  the  catheter  must  be  passed  by  sight,  and  this  is 
preceded  by  careful  disinfection  of  the  external  genitals  and  the 
vestibule.  If  the  sutures  be  aseptic  they  will  not  suppurate, 
and  they  should  be  left  in  place  for  fully  two  weeks.  Should  the 
primary  operation  fail,  the  woman  should  be  advised  to  have 
the  secondary  operation  performed  without  overmuch  delay. 


the  surgery  of  the  puerperium.  177 

Rupture  of  the  Uterus. 

E-upture  of  the  parturient  uterus  constitutes  one  of  the 
most  fatal  as  well  as  most  alarming  of  the  obstetric  complica- 
tions. There  is  scarcely  an  emergency  wliich  calls  for  more 
rapidity  of  judgment  and  of  action ;  for,  as  will  be  noted,  on 
prompt  differential  diagnosis  and  equally  prompt  treatment  the 
life  of  the  woman  depends.  The  accident,  fortunately,  is  an 
infrequent  one,  and  Avill  become  all  the  more  so  as  the  benefits 
of  strictly  elective  obstetric  surgery  become  uniformly  recog- 
nized. 

The  etiological  factor  cannot  be  always  positively  deter- 
mined. In  many  instances  rupture  may  be  traced  directly  to 
the  premature  and  injudicious  administration  of  ergot;  again, 
the  causal  factor  is  the  attempt  to  drag  a  foetus  through  a  pelvis 
where  attention  to  the  ordinary  rules  of  pelvic  mensuration  will 
teach  that  delivery  by  one  or  another  method  is  alone  possible ; 
further,  a  by  no  means  infrequent  factor  has  been  protracted 
labor  with  consequent  thinning  of  the  lower  uterine  segment ; 
and,  finally,  the  operation  of  embryotomy  through  a  greatly- 
contracted  pelvis  may  be  associated  with  rupture  of  the  uterus. 
In  certain  instances  none  of  these  factors  can  be  held  responsible 
when,  in  default  of  a  better  reason,  we  must  consider  that  the 
uterus  has  become  weakened  at  a  certain  point,  and  has  simply 
given  way  at  the  point  of  least  resistance. 

There  are  two  varieties  of  rupture  of  the  uterus,  and  on 
their  differentiation  depend  both  the  prognosis  and  the  treat- 
ment. These  varieties  are  complete  rupture  and  incomplete 
rupture. 

The  complete  rupture  is  intra-peritoneal ;  the  incomplete 
rupture  is  extra-peritoneal.  The  clinical  history  will  ordinarily 
enable  the  physician  to  differentiate  the  variety  of  ru])ture  and 
the  importance  of  accurate  differentiation  will  shortly  be 
apparent. 

Incomplete  rupture  of  the  uterus  may  occur  into  either  of 
the  broad  ligaments,  or  into  the  utero-vesical  space,  or  into  the 


178  OBSTETRIC     SURGERY. 

cul-de-sac  of  Douglas.  In  any  case  the  tear  does  not  extend 
into  the  peritoneal  cavit}^ 

Complete  rupture  of  the  uterus  necessarily  invades  the  peri- 
toneal cavity  associated  with,  in  general,  the  escape  of  the  foetus 
in  part  or  in  whole  into  this  cavity. 

In  incomplete  rupture  the  shock  is  not  as  great  and  the 
loss  of  blood  is  limited  by  the  capacity  of  the  cavity  into  which 
it  is  effused. 

In  complete  rupture  with  extrusion  of  the  entire  foetus 
into  the  peritoneal  cavity  the  shock  is  great,  and  the  hseraor- 
rhage  which  may  take  place  is  only  limited  by  the  amount  of 
blood  the  patient  has  to  lose.  Where  a  portion  only  of  the 
foetus  is  extruded,  the  amount  of  blood  lost  may  be  checked  by 
the  portion  of  the  foetus  which  is  not  extruded  acting  as  a 
tampon. 

The  signs  which  lead  to  diagnosis  of  rupture  of  the  uterus 
are  like  those  which  are  associated  with  haemorrhage.  These 
signs  will  vary  in  intensity  according  as  the  haemorrhage  is  sud- 
den and  great  or  slow,  even  though  gradually  progressive.  Shock, 
rapid  pulse,  pallor,  sighing,  eventually  syncope, — such  are  the 
symptoms  which  should  awaken  the  keen  anxiety  of  the  phy- 
sician. The  only  positive  way  of  making  the  differential  diag- 
nosis between  complete  and  incomplete  rupture  is  to  insert  the 
hand  into  the  uterus,  excepting,  of  course,  in  those  instances 
where  the  foetus  escapes  into  the  peritoneal  cavity,  when,  so  to 
speak,  the  diagnosis  is  made  for  us. 

If  the  rupture  is  incomplete,  surgical  treatment  is  not 
demanded,  certainly  at  the  outset.  The  proper  course  to  pursue 
is  one  of  expectancy.  Where  the  rent  extends  from  the  angle 
of  a  lacerated  cervix  into  the  base  of  the  broad  ligament,  the 
haemorrhage,  in  great  part,  comes  from  the  circular  artery,  and 
this  may  be  checked  by  carrying  a  suture  around  the  artery 
and  tying  it.  AVhere  the  rent  involves  the  broad  ligament  or 
the  anterior  or  the  posterior  cul-de-sac^  the  firm  tamponade 
with  sterilized  gauze  may  check  the  haemorrhage  and  limit  its 


THE  SURGERY  OF  THE  PUERPERIUM. 


Vl9 


extension.  Often,  however,  the  blood  will  continue  to  be 
effused  until  it  has  dissected  the  cellular  tissue  as  far  as  its 
anatomical  boundaries  in  the  given  region  will  allow.  In  other 
words,  the  condition  becomes  one  of  hsematoma — ante-uterine, 
retro-uterine,  or  lateral — into  the  broad  ligament.  Later  on,  if 
the  hsematoma  do  not  become  absorbed,  or  if,  through  some 
faulty  technique,  suppuration   set  in,  surgical  interference  may 


Fig.  82.— Transverse  Rupture  of  the  Uterus. 

become  necessary.  Where  the  rupture  is  intra-peritoneal  the 
prognosis,  in  any  event,  is  most  gloomy.  If  the  foetus  has 
escaped  entirely  or  in  greater  part  into  the  peritoneal  cavity, 
the  only  possible  operation  is  an  abdominal  section,  not  in  the 
hope  of  saving  the  cliild,  but  in  order  to  give  the  woman  a 
single  chance  of  life.  There  is  no  time  in  this  emergency  for 
special  preparations.  The  physician  must  have  the  courage  of 
his  convictions  ;  he  must  open   the  abdomen  at  once,  extract 


180  OBSTETRIC     SURGERY. 

the  foetus,  and  treat  the  uterme  rent  by  sewing  it  up  after  the 
manner  pursued  in  the  Csesarean  section,  or  by  removal  of  the 
entire  uterus  as  is  described  under  the  Porro  operation. 

Where  tlie  rupture  is  complete,  but  the  foetus  has  not 
.escaped  into  the  peritoneal  cavity,  there  is  scope  for  difference 
of  opinion  as  to  the  proper  treatment.  The  results  from  either 
of  the  methods  which  may  be  selected  are  the  reverse  of  bril- 
liant, although  possibly  of  late  years  one  of  them  has  seemed  to 
modify  the  prognosis  for  the  better.  At  first  thought,  immediate 
emptying-  of  the  uterus  and  abdominal  section  would  seem  to  be 
the  desideratum.  The  fact  is,  h6wever,  that  the  woman,  being 
in  deep  shock,  abdominal  section  is  simply  superadding  shock, 
and  the  wonder  is  when  any  recover.  The  alternate  method  is 
to  rapidly  extract  the  foetus  and  then  to  tampon  the  uterus  with 
sterilized  gauze ;  we  thus  compress  the  bleeding-point  and  per- 
haps check  further  loss  of  blood.  Of  late  years  a  few  cases 
treated  after  this  fashion  have  recovered.  If  we  are  fortunate 
thus  to  check  the  haemorrhage,  the  peritoneum  will  take  care 
of  the  blood  which  has  escaped  within  it ;  and  if  the  labor  has 
been  conducted  aseptically  and  the  gauze  inserted  is  aseptic, 
then,  if  the  woman  do  not  die  of  shock,  she  will  not  die  of 
sepsis.  Resort  to  this  method  of  tamponade  is,  however,  only 
possible  where  the  intestines  have  not  protruded  into  the  rent. 
If  this  has  occurred,  w'e  cannot  use  the  tamponade,  because  of 
the  uncertainty  as  to  whether  or  not  the  gut  is  strangulated  at 
the  uterine  rent  or  through  compression  by  th'e  gauze.  There 
can  be  no  choice  of  procedure  in  case  of  intestinal  prolapse ; 
the  physician's  only  recourse  is  abdominal  section. 

In  case  of  incomplete  rupture,  where  the  tampon  has  been 
applied,  the  gauze  should  be  left  in  situ  for  from  thirty-six  to 
sixty  hours.  Adjuvant  treatmant  consists  in  raising  the  foot  of 
the  bed,  bandaging  the  extremities,  giving  strychnia  in  large 
doses  hypodermatically  ( J^-  grain  every  two  hours,  for  its  stimu- 
lating effect  on  the  heart),  and  administering  hot  2-per-cent. 
saline  rectal  injections. 


THE  SURGERY  OF  THE  PUERPERIUM.  181 

A  further  and  very  rare  form  of  uterine  rupture  is  what  is 
termed  "  annular  rupture."  This  consists  in  separation  of  the 
cervix  at  the  utero- vaginal  junction,  either  in  whole  or  in  part. 
The  treatment  requisite  is  ligation  of  the  circular  arteries  in  the 
event  of  their  being  implicated  in  the  rent. 

We  next  pass  to  the  consideration  of  the  puerperal  affec- 
tions due  to  septic  infection,  which  may  require  surgical  aid. 
A  point  to  be  noted  is  that  elective  surgery  is  peculiarly  appli- 
cable to  these  affections,  since  early  treatment  of  this  nature 
very  frequently  spares  the  woman  results  of  the  most  untoward 

nature. 

Endometritis  and  Metritis. 

These  affections  are  considered  together  because  the  one 
is  the  direct  consequence  of  the  other.  On  the  prompt  recog- 
nition of  a  septic  endometritis  depends  the  safety  of  the  tubes, 
ovaries,  peritoneum,  and  not  infrequently  the  life  of  the  woman. 
There  has  been,  of  late  years,  a  radical  change  in  the  metiiod 
of  treatment  of  septic  endometritis.  The  practice  long  in  vogue, 
of  repeatedly  irrigating  the  uterus,  has  been  found  utterly  inef- 
ficient as  a  means  of  guarding  against  infection  of  the  Eallopiau 
tubes,  and  thence  of  the  peritoneal  cavity.  AVhilst  occasionally, 
when  the  local  infection  is  slight  and  superficial,  the  repeated 
douche  suffices  to  limit  and  to  check  extension  of  the  process, 
we  are  never  in  a  position  to  state  definitely  what  cases  will 
yield  to  this  method,  and,  seeing  that  the  aim  is  to  check  the 
septic  process  in  ovo,  so  to  speak,  treatment  of  a  more  radical 
nature  is  favored  by  tlie  majority  of  obstetricians,  particularly 
since  it  may  be  definitely  stated  that  such  treatment,  whilst  most 
efficient  for  good,  carries  with  it  absolutely  no  risk  to  the  patient 
when  properly  and  aseptically  performed. 

The  objections  to  which  the  douche  is  open  are  the  follow- 
ing:  No  matter  how  often  the  douche  is  administered,  all  that 
it  can  accomplish  is  to  wash  the  superficies  of  the  endometrium. 
The  germs  at  work  on  the  surface  are  rendered  inert,  but  those 
in  the  depths  are  not  affected.     To  attempt  to   check  a  septic 


182  OBSTETRIC     SURGERY. 

endometritis  in  this  way  is  very  much  like  trying  to  quench  a 
fire  by  sprinkling  water  on  it  at  intervals.  Further,  since  the 
douches  are  always  administered  witli  the  addition  of  some  anti- 
septic, usually  the  bichloride  of  mercury,  there  is  imminent  risk 
of  poisoning  the  Avoman,  as  numerous  cases  on  record  prove. 
Again,  each  additional  manipulation  to  which  the  woman  is 
subjected  carries  with  it  the  risk  of  additional  septic  infection. 
Lastly,  the  repeated  douche  entails  disturbance  of  a  sick  and 
nervous  woman,  and  this  is  bad  for  the  morale  so  necessaiy  for 
convalescence  from  any  affection,  in  particular  where  the  dis- 
ease is  septic  infection,  when  the  aim  of  all  therapeusis  is  to 
support  the  heart.  For  these  cogent  reasons  the  repeated 
douche  has  been  given  up  by  practically  all  accoucheurs.  The 
following  method,  varied  in  only  insignificant  detail,  has  been 
substituted.  On  the  appearance  of  foetor  of  the  lochia,  which, 
as  a  rule,  is  tlie  precursor  of  developing  septic  endometritis,  a 
vaoinal  douche  is  ordered,  to  certifv  to  the  fact  that  the  foetor  is 
not  due  to  a  vaginal  source.  If  the  foetor  persist  an  intra- 
uterine douche  is  administered,  to  exclude  tlie  presence  of  clots 
or  loose  fragments  of  decidua  in  the  uterus.  If  the  foetor  then 
persist  the  time  for  action  has  come;  for  it  must  be  borne  in  mind 
that,  as  yet,  there  may  be  no  marked  constitutional  disturbance, 
such  as  chill  or  elevation  of  temperature,  or  even  mucli  eleva- 
tion of  the  pulse-rate.  Whenever  possible  the  manipulations 
about  to  be  described  should  be  preceded  by  digital  examination 
of  the  interior  of  the  uterus,  since  not  infrequently  the  symp- 
toms awakening  our  suspicion  are  due  to  the  retention  of  a  piece 
of  placenta  which  is  beginning  to  necrose,  or  to  portions  of  the 
membranes  left  bcliind.  As  a  rule,  it  is  not  necessary  to  anses- 
thetize  tlie  woman  ;  but  if  she  is  hyperaesthetic  or  peculiarly 
nervous,  it  is  better  to  do  so  in  order  to  lessen  shock,  as  also  in 
order  to  enable  the  procedure  to  be  properly  performed.  The 
instruments  necessary  are  a  dull  and  a  sharp  curette  with  long 
handles,  a  vulsellum,  a  pair  of  intra-uterine  packing-forceps,  and 
a  uterine  irrigating-tube.     A  speculum  is  not  strictly  requisite, 


THE  SURGERY  OF  THE  PUERPERIUM.  183 

since  the  manipulations  may  be  performed  along  the  finger, — a 
practice  necessary  where  the  pelvic  floor  has  been  repaired. 
Thoroughness  being  requisite,  however,  the  physician  should 
never  hesitate  to  sacrifice  the  restored  pelvic  floor,  if  necessary, 
in  order  to  carefully  explore  the  uterus. 

Since  it  is  desirable  to  avoid  disturbing  the  woman  as 
much  as  possible,  we  will  describe  the  operation  of  curetting 
the  puerperal  uterus  without  the  aid  of  the  speculum.  As  a 
rule,  also,  we  much  prefer  to  use  the  sharp  curette,  since  when 
the  uterine  mucosa  is  diseased  it  is  absolutely  essential  to 
remove  it  in  its  entirety ;  for  thus  alone  can  we  certainly  eradi- 
cate the  disease  process  and  avoid  a  repetition  of  the  operation. 
The  risk  we  subject  the  woman  to  is  slight  compared  with  that 
she  runs  if  the  operation  be  not  thorough.  This  risk  is  per- 
foration of  the  uterus.  If  requisite  care  be  used  this  risk  is 
slight ;  still,  it  is  desirable  to  have  the  friends  of  the  woman 
distinctly  understand  that  the  procedure  is  not  a  minor  one. 

A  fountain-syringe  connected  with  a  glass  irrigating-tube 
or  with  a  double-current  intra-uterine  catheter,  and  filled  with 
a  solution  of  1  to  8000  bichloride  of  mercury,  should  be  sus- 
pended within  reach,  and  a  pint  bottle  of  peroxide  of  hydrogen 
should  be  opened.  The  hands  of  the  operator,  the  instruments, 
and  the  external  genitals  of  the  woman  should  be  thoroughly 
cleansed ;  the  woman  is  brought  to  the  edge  of  the  couch  and 
her  legs  are  flexed  on  the  abdomen.  At  the  period  of  the 
puerperal  state,  when  the  manipulations  about  to  be  described 
are  indicated,  the  cervical  canal  is  open  so  that  precedent  dila- 
tation will  not  be  necessary.  Again,  whenever  there  is  any- 
thing remaining  in  the  puerperal  uterus  or  whenever  a  septic 
process  exists,  the  same  state  of  the  canal  will  be  found.  The 
index  finger  of  the  left  hand  is  introduced  into  the  vagina  and 
placed  at  the  external  os.  Along  this  finger  the  curette  is 
guided  into  the  uterus,  absolutely  no  force  being  used,  until  the 
loop  of  the  instrument  reaches  the  fundus.  If  digital  examina- 
tion has  revealed  the  presence  of  a  portion  of  retained  secun- 


184  OBSTETRIC     SURGERY. 

dine  or  placenta  undergoing  degeneration,  the  instrument  is 
guided  to  this  and  firm  traction  on  the  handle  will  remove  it. 
Whilst  the  left  hand  is  manipulating  the  handle  of  the  curette, 
the  right  hand  grasps  the  fundus  of  the  uterus  through  the 
abdominal  wall  and  not  only  controls  it,  but  is  ever  conscious 
of  the  action  of  the  curette.  Herein  lies  a  further  value  of 
the  method  of  curetting  without  the  speculum. 

Where  the  entire  endometrium  is  involved  in  the  necrotic 
process,  the  curette,  ever  under  the  control  of  the  external 
hand,  should  be  made  to  traverse  it,  particular  care  being  taken 
to  explore  the  openings  of  the  Fallopian  tubes  into  the  organ. 
When  satisfied  that  the  process  is  thoroughly  eradicated,  the 
curette  is  withdrawn,  the  irrigating-tube  or  the  catheter  is  in- 
serted and  the  uterine  cavity  is  washed  out,  the  antiseptic  solu- 
tion being  at  a  temperature  of  about  115°  F.  When  the 
fountain-syringe  is  empty,  the  peroxide  of  hydrogen  is  poured 
in  and  the  uterine  cavity  is  washed  out  with  this.  The  catheter 
is  now  withdrawn  ;  a  strip  of  sterilized  gauze,  about  two  inches 
wide  and  eighteen  inches  long,  is  grasped  by  the  packing- 
forceps  and  carried  into  the  uterus,  the  greater  portion  of  the 
gauze  being  inserted.     This  insures  free  drainage  externally. 

As  a  rule,  considerable  depression  follows  these  manipula- 
tions where  anaesthesia  has  not  been  resorted  to,  and,  therefore, 
it  is  generally  desirable  to  use  it.  The  gauze  is  left  in  situ  from 
thirty-six  to  forty-eight  hours,  when,  after  renewed  asepsis  of 
the  genitals  and  with  aseptic  hands  the  gauze -is  removed.  The 
uterus  is  irrigated  with  hot  1  to  8000  bichloride,  or  with  2-per- 
cent, creolin,  and  a  second  strip  of  gauze  is  inserted,  on  this 
occasion  not  being  packed  in,  but  being  placed  more  as  a  drain. 
If  the  curetting  has  been  thorough  it  will  rarely  be  necessary 
to  repeat  it ;  the  local  septic  process  is  either  at  an  end  or 
it  has  extended  to  the  parenchyma  of  the  uterus,  giving 
rise  to  a  metritis,  or  to  the  tubes  and  ovaries,  giving  rise  to  a 
salpingitis  or  to  an  oophoritis.  It  is  to  avoid  these  untoward 
complications   that  it  is   essential  to   recognize  a  septic    endo- 


THE  SURGERY  OF  THE  PUERPERIUM.  185 

metritis  early,  and  to  treat  it  radically  after  the  manner  just 
described. 

Whilst  the  method  of  curetting  through  the  speculum  is 
not  favored  by  us,  since  it  is  indorsed  by  many,  we  deem  it 
essential  to  describe  it.  The  additional  instruments  requisite 
are  a  speculum  and  a  vulsellum  forceps.  If  the  operator  prefer 
the  Sims  speculum,  the  woman  is  placed,  of  course,  in  the  left 
lateral  position,  otherwise  the  Edebohl  or  the  Simon  speculum 
will  answer  for  the  dorsal  position. 

After  due  asepsis  the  cervix  is  exposed  through  the  specu- 
lum, the  vulsellum  is  made  to  grasp  the  anterior  lip  of  the 
cervix,  and  the  curette  is  inserted  by  sight  instead  of  by  touch. 
The  manner  of  curetting  is  exactly  similar  to  the  process  just 
described. 

Frequently,  after  the  curetting,  the  woman  has  a  chill ;  but, 
as  a  rule,  this  has  no  significance,  being  entirely  nervous  in 
character.  If,  after  the  lapse  of  thirty-six  hours,  the  tempera- 
ture fall  and  the  pulse  approximate  nearer  the  normal  (and 
this  fall  of  the  pulse  is  the  chief  good  omen),  the  chances  are 
that  the  operation  has  been  timely  and  that  the  woman  has 
been  spared  extension  to  the  parenchyma  of  the  uterus  or  to  the 
tubes  and  ovaries.  If,  on  tlie  other  hand,  the  septic  phenomena 
become  intensified,  then  the  physician  must  suspect  extension, 
and  his  position  must  become  an  exceedingly  alert  one.  A  sup- 
purative metritis  or  salpingo-oophoritis  can  be  met  in  only  one 
way,  and  this  is  through  abdominal  section.  Even  then  the 
prognosis  is  most  gloomy,  since  septic  processes  of  tliis  nature 
are  ordinarily  associated  with  deep  systemic  lymphatic  absorp- 
tion,— an  affection  against  which  our  therapeutic  resources,  both 
medical  and  surgical,  as  yet  avail  but  little.  If,  however,  there 
should  be  reasonable  doubt  as  to  the  systemic  infection,  the 
physician  must  not  hesitate,  but  proceed  to  the  one  operation 
which  offers  the  woman  a  single  chance  of  life,  and  this  is 
ahdominal  section  with  extirpation  not  alone  of  the  purulent 
appendages,  but  also  of  the  septic  uterus.     This  seems  a  forlorn 


186  OBSTETRIC     SURGERY. 

liope,  and  so  it  is ;  but  the  sole  alternative  in  these  aggravated 
types  of  sepsis  is  to  allow  the  woman  to  die  of  septicaemia  ema- 
nating from  the  uterus  or  the  appendages,  and  this  course  of 
action  is  reprehensible,  seeing  that  sometimes,  although  very 
rarelv,  even  such  desperate  cases  recover  under  the  bold  use  of 
the  knife, 

Unibrtunately,  septic  metritis,  salpingitis,  and  oophoritis, 
when  developing  during  the  puerperium,  are  of  such  a  virulent 
type  and  the  associated  general  systemic  infection  is  so  pro- 
found that  we  can  expect  but  one  result,  no  matter  what  the 
therapeusis,  and  this  result  is  death.  The  women  die  not  so 
much  because  of  the  local  lesions  as  because  of  the  deep  sys- 
temic infection.  Still,  since  there  are  now^  and  then  recorded 
Ciises  where  aggressive  surgery  has  resulted  in  ultimate  recovery, 
in  a  given  case  the  physician  is  bound  to  take  into  consideration 
the  advisability  of  resorting  to  abdominal  section.  The  steps 
of  the  operation  are  similar  to  those  which  are  called  for  when 
total  hysterectomy  is  performed  for  other  causes.  The  object  of 
the  operation  being  to  remove  from  the  body  the  source  of  the 
systemic  infection,  ablation  of  the  involved  organs  must  be 
thorough;  that  is  to  say,  the  abdominal  cavity  having  been 
opened,  the  entire  uterus  with  the  appendages  must  be  removed 
in  accordance  with  the  steps  which  are  laid  down  in  modern 
treatises  on  gynaecology. 

As  a  rule,  there  is  associated  witli  metritis  and  septic  appen- 
dages the  next  subject  we  are  called  upon  to  consider  : — 

Puerperal  Peritoxitis. 
In  considering  this  affection  from  a  surgical  stand-point,  it 
is  essential  to  note  the  change  in  practice  which  the  last  decade 
has  witnessed,  without,  however,  it  must  be  confessed,  any 
special  change  in  secured  results.  It  is  a  fact  beyond  dispute 
that,  no  matter  what  the  form  of  treatment  employed,  the  vast 
proportion  of  cases  of  puerperal  peritonitis  die.  Large  doses 
of   opium,  saline  catharsis,  abdominal  section, — each   of  these 


THE  SURGERY  OF  THE  PUERPERIUM.  187 

approved  methods  has  an  exceedmgly  high  mortality  percentage. 
It  must  be  remembered  that  puerperal  peritonitis,  whether  local 
or  general,  is  due  to  infection  by  one  or  two  routes,  aside  from 
instances  when  peritonitis  complicates  the  puerperal  state,  due 
to,  we  will  say,  rupture  of  an  ovarian  or  tubal  abscess  or  to  a 
purulent  appendicitis.  The  two  modes  of  infection  are  either 
by  direct  extension  from  the  uterine  cavity  or  by  lymphatic 
absorption.  In  the  former  instance  the  peritonitis  is  likely  to  be 
and  to  remain  local ;  in  the  latter  instance  it  is  likely  to  become 
general.  The  systemic  infection  is  by  no  means  so  exaggerated, 
as  a  rule,  in  local  as  in  general  purulent  peritonitis.  In  general 
peritonitis  the  affection  is  secondary  to  general  systemic  infec- 
tion. Not  alone  is  the  peritoneal  cavity  filled  with  multiple 
abscesses,  but  the  lympliatics  of  the  entire  system  are  gorged 
with  the  infectious  element  and  deposit  it  all  over  the  body. 
The  women  die  no  matter  what  the  form  of  treatment  employed, 
not  because  of  the  peritonitis,  but  because  of  the  deep  general 
systemic  infection.  It  is  absolutely  essential,  therefore,  to 
endeavor  to  differentiate  local  from  general  purulent  peritonitis. 
Frequently  this  is  possible;  then,  again,  the  symptomatology  of 
the  one  suggests  the  other.  The  physical  signs  may  be  as 
aggravated,  frequently  more  so,  in  instances  of  local  as  in  cases 
of  general  peritonitis.  And  yet,  no  matter  how  extremely 
unfavorable  the  case  may  appear,  sometimes  speedy  surgical 
action  reveals  a  local  instead  of  a  general  peritonitis,  and  some- 
times the  women  recover. 

So  important  is  the  factor  of  diagnosis  that  every  means 
should  be  utilized  toward  reaching  the  desideratum, — a  differ- 
ential diagnosis  between  local  and  general  peritonitis.  Examina- 
tion of  the  uterus  with  the  finger  to  exclude  septic  focus  there ; 
palpation  of  the  appendages,  particularly  by  rectum,  and,  in  case 
of  doubt,  with  the  assistance  of  deep  surgical  antesthesia, — 
these  and  every  other  means  should  be  used  to  clear  the  scene. 

Notwithstanding  all  these  differential  diagnostic  means, 
there  are  a  certain  proportion  of  cases  where  the  physician  will 


188  OBSTETRIC     SURGERY. 

still  remain  in  doubt  as  to  whether  he  is  dealing  with  a  local  or 
with  a  general  peritonitis.  Then,  in  remembrance  of  the  fact 
that,  if  the  affection  be  local  although  simulating  general  peri- 
tonitis, the  Avoman's  chance  of  life  depends,  in  all  probability, 
on  his  speedy  action,  gloomy  as  is  the  prognosis,  it  is  his  duty 
to  resort  to  the  single  therapeutic  measure  which  affords  a  gleam 
of  hope.  It  must  never  be  forgotten  that  surgery  is  full  of  sur- 
prises, and  that  our  finite  methods  of  diagnosis  must  often 
be  supplemented  and  aided  through  resort  to  most  desperate 
measures. 

Local  peritonitis  presents  itself  under  two  forms, — as  extra- 
peritoneal and  as  incapsulated  intra-peritoneal.  The  latter, 
however,  is  really  extra-peritoneal  in  the  sense  that  it  is  shut  off 
from  the  general  peritoneal  cavity  by  adhesions,  being  originally 
intra-peritoneal.  Etiologically  the  true  extra-peritoneal  exudate 
which  may  suppurate  is  not  usually  associated  witli  tubal  or 
ovarian  infection,  whilst  the  latter  form  is  generally  the  sequela. 
This  is  the  main  reason  why  a  true  cellidar  abscess  carries  a  less 
grave  prognosis  than  the  intra-  and  yet  extra-  peritoneal  variety. 
The  symptomatology  of  true  pelvic  abscess — that  is  to  say,  of 
abscess  in  the  pelvic  cellular  tissue — may  be  as  aggravated  in 
type  as  the  intra-peritoneal  form ;  and  yet  the  outcome  of  sur- 
gical treatment  is  much  more  favorable.  Whenever  the  local 
and  the  general  symptoms  point  to  the  existence  of  pus  in  the 
pelvic  cellular  tissue,  the  sooner  it  is  evacuated  the  better.  As 
a  rule,  the  point  of  election  for  operating  will  be  the  vagina, 
since  it  is  here  that  an  abscess  of  this  character  usually  points. 

The  operation  is  performed  as  follows  :  Thorough  asepsis  of 
the  external  genitals  having  been  secured,  under  the  guidance 
of  the  aseptic  finger  in  the  vagina  an  aspirator-needle  is  plunged 
into  the  softened  exudate  at  a  point  close  to  the  cervix,  in  order 
to  avoid  injuring  the  ureter.  Along  this  aspirator-needle,  as  a 
guide,  a  narrow-bladed  knife  is  passed  and  the  opening  into  the 
cavity  is  enlarged.  A  steel-branched  dilator  is  next  inserted, 
and  the  opening  is  torn  wider.     The  finger  is  then  inserted  into 


THE  SURGERY  OF  THE  PUERPERIUM.  189 

the  cavity,  and  the  different  chambers  which  frequently  go  to 
make  up  the  cavity  are  broken  down.  The  cavity  is  then  irri- 
gated with  bichloride  or  creolin  solution,  and  next  washed  out 
with  the  full-volume  peroxide  of  hydrogen.  A  T-shaped  rubber 
drain-tube  is  then  inserted,  and  through  this  the  cavity  is 
washed  out  daily  until  suppuration  is  at  an  end.  If  the  cause 
of  the  symptoms  has  been  the  cellular  abscess,  in  twenty-four 
to  tliirty-six  hours  the  general  condition  of  the  woman  will  have 
altered  materially  for  tlie  better,  and  as  soon  as  she  has  thrown 
off  the  general  sepsis  she  will  rapidly  convalesce. 

Such  is  the  treatment  and  such  the  course  of  events  in 
pure  cellular  abscess,  which,  we  repeat,  may  present  as  aggra- 
vated symptoms  as  the  intra-peritoneal  variety.  Earely  these 
cellular  abscesses  do  not  point  in  the  vagina,  but  above  Pou- 
part's  ligament.  Then  the  point  of  election  for  incision  is  at 
this  site.  The  cavity  is  entered  by  an  incision  parallel  to  Pou- 
part's  ligament,  is  washed  out  after  the  same  fashion,  and, 
where  possible,  a  counter-opening  is  made  into  the  vagina, 
since  thus  we  obtain  better  drainage,  and,  therefore,  speedier 
convalescence. 

It  is  the  intra-extra-peritoneal  variety  of  abscess  which 
gives  the  most  trouble,  both  from  the  diagnostic  and  the  thera- 
peutic stand-point.  General  purulent  peritonitis,  being  an  epi- 
phenomenon  of  general  septic  infection,  has  as  yet  proven 
rebellious  to  every  therapeutic  measure.  The  woman  dies  not 
because  she  is  suffering  from  peritonitis,  but  because  she  is 
deeply  poisoned.  The  post-mortem  findings  explain  this.  Xot 
only  does  the  peritoneal  cavity  contain  multiple  abscesses,  but 
the  venous  and  lymphatic  systems  are  similarly  gorged.  What 
then,  it  may  reasonably  be  asked,  is  the  use  of  surgical  pro- 
cedure'? Because,  as  we  have  already  stated,  the  symptoma- 
tology of  local  peritonitis  sometimes  is  suggestive  of  general 
peritonitis,  and,  therefore,  abdominal  section,  even  though  the 
case  appear  of  the  most  desperate  type,  may  reveal  a  local  peri- 
tonitis amenable  to  treatment.     It  must  further  be  remembered 


190  OBSTETRIC     SURGERY. 

that  peritonitis,  associated  witli  purulent  appendicitis,  may  com- 
plicate the  puerperal  state,  and  here  prompt  section  may  result 
in  the  saving-  of  life.  In  this  desperate  disease  one  must  have 
the  courage  of  strong  convictions,  and  operate,  even  though 
the  battle  seem  lost  before  action.  We  are  absolutely  assured 
that  nothing  is  to  be  gained  from  therapeutic  nihilism,  at  any 
rate. 

The  abdominal  cavity  is  opened  in  the  usual  way,  and,  if 
we  are  fortunate  enough  to  find  a  local  peritonitis  instead  of  a 
general,  the  abscess-cavity  is  emptied,  is  washed  out  with  per- 
oxide of  hydrogen  (full  strength),  and  is  packed  with  sterilized 
gauze.  If,  however,  the  peritonitis  is  general  and  purulent,  then 
the  most  we  can  do  is  to  break  up  the  multiple  abscess-cavities 
as  far  as  we  can  detect  them,  repeatedly  flood  the  peritoneal 
cavity  with  hot  sterilized  water,  and  pack  the  lower  part  of  the 
pelvis  with  gauze.  If  the  woman  recover,  the  result  is  fairly 
miraculous.  If  she  die,  the  physician  has  the  satisfaction  of 
knowing  that  he  has  done  his  full  duty  by  his  patient  and  that 
the  result  was  in  no  sense  due  to  surgery. 

Puerperal  Mastitis. 

In  the  light  of  our  present  knowledge,  puerperal  mastitis 
must  be  considered  as  due  to  infection.  The  germs  or  infectious 
material  gain  entrance  through  the  lacteal  ducts  and  cause  the 
inflammatory  process  which  may  be  aborted  or  which  may 
suppurate. 

In  the  latter  event,  we  have  the  affection  which  is  termed 
mammary  abscess.  Two  varieties  of  mammary  abscess  are  to 
be  differentiated, — the  glandular  and  the  sub-glandular.  The 
former  is  not  specially  uncommon ;  the  latter  is  exceedingly  so. 
The  one  is  readily  recognized ;  the  other  is  not,  running  an 
insidious  course  and  undermining  the  gland  often  before  its 
presence  is  made  sufficiently  known  to  call  for  the  recognized 
treatment. 

Whilst  much  may  be  accomplished  in  the  way  of  aborting 


THE  SURGERY  OF  THE  PUERPERIUM.  191 

suppuration  through  the  use  of  the  ice-bag,  or,  if  the  individual 
prefer,  by  hot  applications,  as  soon  as  the  physician  is  sure  of 
tlie  presence  of  pus,  the  earlier  it  is  evacuated  the  better  for  the 
welfare  of  the  breast.  Glandular  abscess  ought  to  be  recog- 
nized early;  the  reverse  holds  true  in  case  of  the  sub-glandular 
variety.  And  yet  this  latter  form  is  the  one  wliicli  always  even- 
tually does  the  most  damage  to  the  glandular  tissue,  and, 
besides,  subjects  the  woman  to  the  serious  risk  of  perforation 
into  the  pleural  cavity  before  there  exists  at  times  sufficient 
evidence  of  pus  to  justify  incision.  In  these  obscure  cases,, 
when,  under  the  use  of  ice  or  heat,  the  cardinal  symptoms  of 
inflammation  do  not  abate,  exploration  with  the  aspirator- 
needle  should  be  resorted  to.  Of  course,  this  aspiration  should 
be  strictly  aseptic,  otherwise  a  non-suppurating  exudation  will 
be  converted  into  a  suppurating. 

When  the  aspirator-needle  reveals  pus,  or  when  there  is 
evidence  of  pus  without  aspiration,  the  sooner  the  gland  is 
incised  the  better.  The  line  of  incision  should  be  radiating 
from  the  nipple  outward,  in  order  to  avoid  injuring  more  of  the 
lacteal  ducts  than  are  already  involved  in  the  suppurative  pro- 
cess. The  affected  breast  should  be  scrubbed  with  soap  and 
water,  then  with  1  to  8000  bichloride  solution,  and  finally 
washed  with  sulphuric  ether.  With  a  clean  knife  an  incision 
is  made  through  the  gland  down  to  the  abscess-cavity.  When 
this  has  been  opened,  the  finger  is  inserted  in  order  to  break  up 
all  the  cavities  into  which  the  abscess  is  apt  to  be  divided. 
After  thorough  irrigation  with  bichloride,  the  full-strength  per- 
oxide of  hydrogen  is  poured  in  and  the  cavity  is  packed  with 
sterilized  gauze.  A  firm  compression-binder  is  applied.  At 
the  end  of  twentv-four  hours  the  dressino-  is  removed,  the  cavitv 
is  again  irrigated,  a  gauze  drain  is  inserted,  and  a  large  sterilized 
sponge  is  placed  over  the  breast.  A  firm  binder  is  applied  over 
all.  This  method  of  compression  secures  close  apposition  of 
the  abscess  cavity-walls  and  prevents  the  further  pocketing 
of  pus.     In  the  event  of  there  being  no  evidence  from  the  side 


192  OBSTETRIC     SURGERY. 

of  the  pulse  and  the  temperature  of  septic  absorption,  this 
second  dressing  need  not  be  changed  for  a  number  of  days, 
when  the  cavity  may  be  found  entirely  closed. 

In  more  complicated  cases,  where,  for  instance,  a  submam- 
mary abscess  has  not  been  recognized  in  its  early  stages,  the 
pus  may  be  found  to  have  dissected  the  entire  gland,  and  then 
all  attempts  to  save  the  lacteal  ducts  are  futile.  As  many 
counter-openings  as  are  necessary,  in  order  to  secure  efficient 
drainage,  must  be  made,  and  every  possible  eflbrt  is  requisite  to 
prevent  the  pocketing  of  pus  under  the  pectoral  muscle  and 
toward  the  pleural  cavity. 

As  the  principles  of  asepsis  as  applied  not  alone  to  the 
maternal  breast,  but  also  to  the  infant's  mouth  before  it  is 
applied  to  the  breast,  are  understood  by  nurses  and  exacted  by 
physicians,  mammary  abscess  will  become  one  of  the  rarest 
complications  of  the  puerperal  state.  In  large  maternity  hos- 
pitals, where  the  strictest  care  is  required,  the  fact  is  that 
mammary  abscess  is  now  rarely  met  with,  and,  when  it  is,  the 
nurse  has  been  at  fault,  unless  the  mother  has  handled  her 
breast  with  unclean  hands. 


CHAPTER    IX. 

ECTOPIC    GESTATION. 

The  subject  of  ectopic  gestation  is  of  prime  interest  to  the 
general  practitioner,  for  the  reason  that  on  his  abihty  to  recog- 
nize the  condition  early  depends  usually  the  life  of  his  patient. 
Seeing  that  the  majority  of  obstetric  work  falls  within  the 
province  of  the  general  practitioner,  it  seems  appropriate  that 
ectopic  gestation  should  be  considered  from  its  tlierapeutic  side 
in  a  work  dealing  with  obstetric  surgery. 

We  shall  not  enter  into  a  discussion  of  the  value  of  elec- 
tricity in  the  treatment  of  ectopic  gestation.  Sufficient  the 
statement  that  it  seems  proven  that  in  its  earlier  stages  the 
development  of  the  ovum  may  be  checked  through  the  adminis- 
tration of  galvanism  or  faradism.  Our  aim  will  be  fulfilled 
when  we  have  tersely  noted  the  diagnostic  points  and  have  laid 
stress  on  the  surgical  treatment  of  ectopic  gestation. 

We  shall  consider  this  subject  from  the  now  generally 
accepted  view  that  primarily  all  ectopic  gestations  are  tubal. 
About  the  tenth  week  rupture  of  the  tube  occurs  in  one  of  two 
directions:  (1)  into  the  general  peritoneal  cavity;  (2)  into  the 
broad  ligament.  In  the  latter  event  the  gestation  may  or  may 
not  continue  to  term. 

The  surgery  of  ectopic  gestation,  therefore,  envisages  the 
subject  from  a  number  of  stand-points  :  1.  Before  tubal  rupture. 
2.  After  rupture  {a)  into  the  peritoneal  cavity;  {h)  into  the 
broad  ligament.  3.  During  development  to  term.  4.  At  term 
and  after  term. 

Essential  to  any  treatment  is  accurate  diagnosis.  Before 
tubal  rupture  this  will  rarely  be  possible  beyond  strong  hypoth- 
esis. At  the  time  of  rupture  the  symptomatology  will  ordi- 
narily establish  the  diagnosis.  Daring  development  to  term 
and  at  term  the  diagnosis  is  often  in  doubt,  not  as  to  whether 

^^  (193) 


194  OBSTETRIC     SURGERY. 

pregnancy  exists,  but  as  to  whether  it  be  uterine  or  extra- 
uterine. After  term,  if  the  precedent  history  be  clear,  the  diag- 
nosis is  estabUshed  ;  but  often  it  may  be  made  only  on  abdominal 
section. 

Before  rupture — that  is  to  say,  before  the  tenth  to  twelfth 
week  of  gestation — the  diagnosis  may  be  reasonably  predicated 
on  the  following  history:  A  period  of  amenorrhoea,  associated 
especially  with  the  reflex  disturbances  of  pregnancy,  followed 
by  irregular  liEemorrhages.  Ordinarily  there  is  a  history  sug- 
gestive of  precedent  disease  of  the  uterus  and  appendages,  and, 
as  a  rule,  the  woman  has  never  conceived  before  or  there  has 
been  a  period  of  protracted  sterility.  On  local  examination 
(vaginal  and  rectal)  the  uterus  is  found  enlarged,  and  one  or 
the  other  tube  as  well  (either  in  situ  or  posterior  to  the  uterus). 
The  woman,  furthermore,  often  complains  of  sharp  attacks  of 
abdominal  pain,  which  are  the  associates  of  the  distension  of  the 
tube,  or  are  due  to  peritoneal  irritation  from  tearing  of  the 
peritoneal  covering  of  the  tube.  This  ensemble  of  symptoms 
should  at  once  awaken  the  suspicion  of  the  existence  of  tubal 
gestation.  It  is  at  this  period  that  galvanism  may  be  resorted 
to  with  safety,  since  it  may  do  good  and  can  only  do  harm  in 
that  its  use  postpones  resort  to  surgery,  if  it  do  not  render  this 
unnecessary. 

The  symptoms  of  rupture  vary  according  as  the  accident 
occurs  into  the  peritoneal  cavity  or  into  the  broad  ligament. 
Accurate  differentiation  is  essential,  since  there  is  but  one  pos- 
sible line  of  action  in  the  former  event,  and  this  is  abdominal 
section  as  soon  as  feasible.  The  main  symptom  is  collapse 
of  varying  degree,  with  the  formation  of  a  tumor  in  case  of 
rupture  into  the  broad  ligament.  Where  the  rupture  is  intra- 
peritoneal, the  symptoms  suggestive  of  haemorrhage  (fainting, 
sighing,  rapid  pulse,  increasing  pallor)  are  usually  more  grave 
than  where  the  rupture  is  extra-peritoneal.  The  reverse  may 
hold,  however,  since  the  intra-peritoneal  bleeding  may  be 
gradual  and  the  extra-peritoneal  profuse.     The  precedent  his- 


ECTOPIC    GESTATION.  195 

tory,  however,  and  the  immediate  symptoms  should  certify  to 
the  diagnosis  almost  always  so  as  to  lead  to  the  adoption  of  the 
proper  therapeusis,  wliich  is  immediate  abdominal  section  in 
case  of  intra-peritoneal  haemorrhage,  and  expectancy  in  case  of 
broad-ligament  ligemorrhage. 

The  symptomatology  of  ectopic  gestation  after  primary 
extra-peritoneal  rupture  may  be  self-suggestive  as  regards  diag- 
nosis, and  again  may  be  very  obscure.  So  long  as  the  foetus  is 
alive,  the  hearing  of  the  heart-sounds  and  the  perception  of 
movements  will  certify  as  to  pregnancy  ;  but,  usually,  short  of 
exploration  of  the  uterus,  normal  gestation  cannot  be  excluded. 
After  foetal  death,  whilst  the  precedent  history  will  suggest  the 
likelihood  of  ectopic  gestation,  abdominal  section  alone,  in  the 
vast  majority  of  cases,  will  clear  the  diagnosis. 

The  following  conditions  may  simulate  intra-peritoneal 
rupture  of  ectopic  gestation :  Abortion,  dysmenorrhoea,  rupture 
of  some  abdominal  organ  with  escape  of  its  contents  into  the 
peritoneal  cavity,  and  pelvic  peritonitis. 

The  following  conditions  may  be  mistaken  for  extra-peri- 
toneal rupture  of  ectopic  gestation :  Intra-peritoneal  rupture 
of  the  same  condition,  heematoma  of  the  broad  ligament  from 
other  causes,  exudate  in  the  cellular  tissue  of  the  ligament, 
and  cyst  of  the  broad  ligament  or  abscess  within  it. 

In  both  series  of  instances,  attention  to  the  history  and 
careful  physical  examination,  if  need  be  under  an  anaes- 
thetic, will  often  clear  the  diagnosis.  Peritonitis  may  be  ex- 
cluded by  the  elevation  of  temperature,  which  exists,  usually, 
from  the  outset.  Exploration  of  the  uterus,  together  with  care- 
ful bimanual,  rectal  and  vaginal,  will  exclude  abortion,  aside 
from  the  fact  that  shock  rarely  exists  in  the  latter  condition, 
except  the  woman  be  hyperaesthetic  and  hysterical,  when  it  is 
never  deep  and  progressive,  but  transient.  In  case  of  rupture 
of  some  viscus,  such  as  the  appendix  vermiformis,  with  escape 
of  its  contents,  where  the  depression  is  extreme,  the  therapeutic 
indication  is  the  same  as  for  rupture  of  a  tubal  pregnancy  into 


196  OBSTETRIC     SURGERY. 

the  peritoneal  cavity.  The  formation  or  the  presence  of  a 
tumor  in  one  or  the  other  broad  hgament,  no  matter  what  the 
condition,  will  lack  the  urgency  calling  for  immediate  surgery. 
Finally,  there  are  instances  where  combined  uterine  and  extra- 
uterine gestation  exist,  and  here,  no  matter  how  refined  our 
diagnostic  aids,  the  question  can  alone  be  settled  by  exploration 
of  the  uterus,  and,  in  the  event  of  supposed  intra-peritoneal 
rupture,  by  abdominal  section. 

The  diagnosis  of  ectopic  gestation  having  been  made  with 
sufficient  exactitude  to  swerve  the  judgment  of  two  or  more 
physicians  in  its  favor,  the  woman  must  be  regarded  as  subject 
to  a  greater  or  a  less  imminent  risk,  according  to  the  period  of 
gestation.  The  ovum  is  a  parasite  of  ill  omen  to  its  mother, 
and  its  destruction  or  removal  is  called  for  when,  by  so  doing, 
the  immediate  or  the  ultimate  safety  of  the  woman  so  requires. 

Prior  to  tubal  rupture,  when  the  diagnosis  is  always  uncer- 
tain, arrest  of  the  growth  of  the  ovum  by  means  of  galvanism 
or  of  faradism  is  justiiiable.  Absorption  of  so  small  a  mass  as 
the  ovum  is  prior  to  the  eighth  or  tenth  week  is  perfectly  pos- 
sible, and,  if  this  absorption  should  not  occur,  the  woman  at 
best  is  carrying  a  diseased  tube,  which  at  any  time  when  it. 
seems  desirable  may  be  removed  by  abdominal  section.  Where, 
however,  the  physician  is  a  skilled  operator,  the  immediate  and 
future  welfare  of  the  woman  is  best  secured  through  resort  to 
abdominal  section.  The  steps  of  the  operation  are  the  follow- 
ing :  The  abdomen  and  the  pubes  having  been  shaved  and  the 
integument  having  been  cleansed  by  thorough  scrubbing  with 
soap  and  water,  followed  by  1  to  1000  bichloride  solution,  the 
woman  is  anaesthetized.  The  bladder  is  emptied.  The  instru- 
ments (scalpel,  artery-forceps,  ligature-carrier,  Peaslee-Hagedorn 
needle)  should  be  thoroughly  sterilized,  and  the  hands  of  the 
operator  and  of  his  assistants  should  be  scrupulously  cleansed. 
It  must  be  remembered  that  septic  infection  is  the  sole  risk  the 
woman  runs  in  the  hands  of  an  operator  familiar  with  the 
technique. 


ECTOPIC    GESTATION.  197 

The  operation  is  likely  to  prove  of  shorter  duration  if  the 
woman  be  placed  in  the  Trendelenburg  position.  This  position 
may  be  improvised  by  tying  an  ordinary  kitchen-chair  to  the 
table  so  as  to  form  the  inclined  plane.     (See  next  page.) 

In  addition  to  the  instruments,  the  operator  should  have 
prepared  at  least  four  large,  fiat,  gauze  pads  and  one  dozen 
small  gauze  sponges.  A  quart-bottle  full  of  1-per-cent.  hot 
(120°  F.)  sterilized  salt-solution  should  be  ready  to  irrigate  the 
peritoneal  cavity,  in  the  event  of  threatened  collapse  from  un- 
avoidable haemorrhage.  The  peritoneum  rapidly  absorbs  the 
salt-solution,  and  it  forms  our  readiest  restorative. 

The  usual  incision  is  made  down  to  the  peritoneum,  about 
three  inches  in  length,  extending  upward  from  above  the  pubes. 
Any  haemorrhage  is   checked  by  torsion  of  the   small  vessels. 


Fig.  83. — Cleveland's  Ligature-Carrier. 


Before  opening  the  peritoneum  the  operator  should  emphasize 
his  injunction  that  absolutely  no  antiseptics  are  to  be  used  in 
the  further  progress  of  the  operation. 

The  peritoneal  cavity  having  been  entered,  one  or  more  of 
the  large  gauze  pads,  wrung  dry  from  the  sterilized  water,  are 
inserted  to  keep  the  intestines  from  the  abdominal  opening. 
With  one  or  two  fingers  the  operator  liberates  the  tube  and 
ovary  (if  adherent)  and  brings  them  out  of  the  abdominal 
incision.  The  ovarian  artery  being  very  vascular,  it  is  desir- 
able, when  feasible,  to  isolate  it  and  tie  it  separately  with 
medium-sized  sterilized  silk.  The  pedicle  is  transfixed  by  the 
ligature-carrier;  a  stout,  sterilized,  Chinese-silk  ligature  is 
brought  through,  the  ends  are  crossed  and  firmly  tied,  after 
the  usual  manner.     The  appendages  are  then  removed. 


198 


OBSTETRIC     SURGERY. 


The  tube  and  ovary  of  the  opposite  side  are  next  exam- 
ined, and,  if  diseased,  are  similarly  tied  otf. 

The  pads  are  now  removed  from  the  abdominal  cavity. 
If  the  operation  has  not  been  associated  with  haemorrhage,  it  is 
not  necessary  to  mop  out  or  to  irrigate  the  field  of  operation. 
In  case  the  pulse  is  flagging,  however,  irrigation  with  the  salt 
solution  should  be  resorted  to. 

The   abdominal    incision   is  closed  by  deep  silk-worm-gut 


Fig.  84. — Emergency  Trendelenburg  Posture.     (The  inclined  plane  is  formed  by 
an  ordinary  chair  being  tied  on  a  kitchen-table.) 

sutures  transfixing  all  the  tissues  and  including  carefully  the 
fascia  of  the  recti. 

In  the  event  of  the  woman  not  being  seen  until  tubal  rupt- 
ure has  occurred,  the  surgical  treatment  must  be  immediate  if 
the  haemorrhage  be  intra-peritoneal.  The  steps  of  the  opera- 
tion are  similar  to  those  just  stated,  except  that,  on  opening  the 
peritoneal  cavity,  no  time  should  be  lost  in  grasping  the  rupt- 
ured tube  and  tying  it  off,  for  tliis  is  tlie  source  of  the  haemor- 
rhage. The  peritoneal  cavity  should  then  be  irrigated  with 
hot,  sterile  salt-solution  to  act  as  a  restorative  and  to  wash  out 


ECTOPIC   GESTATION.  199 

the  major  portion  of  the  blood  and  clots.  What  must  perforce 
be  left  behind  the  peritoneum  will  take  care  of,  unless  it  be 
septic.  Where  this  possibility  is  feared,  drainage  by  gauze 
through  Douglas's  cul-de-sac  is  preferable  to  attempts  at  drain- 
age through  the  abdominal  incision. 

When  the  diagnosis  of  rupture  into  the  broad  ligament 
(extra-peritoneal  rupture)  has  been  reached  the  therapeusis 
should  be  strictly  expectant ;  operative  treatment  is  rarely  called 
for.  If  the  woman  be  kept  in  the  recumbent  position  until  the 
hsematoma  becomes  smaller,  but  little  other  treatment  will  be 
necessary,  beyond  the  self-suggestive  means  for  meeting  the 
greater  or  less  acute  anaemia  from  which  the  woman  is  sufFerino-; 
such  as  frequent  hot  water  (115°  F.),  sahne  (1  per  cent.),  rectal 
irrigation,  strychnine  hypodermatically  (^V  grain  every  three  to 
four  hours),  etc.  Rarely  the  blood-clot  breaks  down  into  pus 
from  septic  infection.  An  opening  should  then  be  made  into 
the  sac  from  the  vagina.  The  pus  must  be  thoroughly  evacu- 
ated, the  sac  washed  out  with  the  full-strength  solution  of  per- 
oxide of  hydrogen,  and  drainage  resorted  to. 

In  a  small  proportion  of  cases  the  ovum  survives  the  extra- 
peritoneal rupture  and  continues  to  grow.  The  woman  from 
now  until  term  is  in  constant  danger  from  the  possibility  of 
secondary  rupture  into  the  peritoneal  cavity.  Every  day  the 
increasing  size  of  the  child  and  of  the  placenta  adds  to  the 
danger  of  this  accident.  The  life  of  the  woman  alone  is  to  be 
taken  into  consideration.  The  chances  that  development  will 
continue  and  the  child  reach  full  term  are  small,  and  even  if  it 
should,  and  be  safely  removed,  it  rarely  survives  the  first  few 
weeks,  and  is  rarely,  also,  perfectly  formed. 

Inasmuch  as  the  continuous  growth  of  the  child  constantly 
increases  the  danger  which  the  woman  must  encounter,  it  is  the 
duty  of  the  physician  to  destroy  it  as  soon  as  it  has  been  de- 
termined that  development  is  taking  place.  If  development 
has  continued  beyond  the  fourth  month,  the  death  of  the  child 
will  not  increase  the  woman's  safety.     The  sac  may  have  formed 


200  OBSTETRIC     SURGERY. 

adhesions  with  loops  of  intestine,  and  throngh  this  source  sepsis 
may  have  entered  the  system.  In  such  cases  it  is  necessary  to 
carefully  watch  the  woman,  and,  as  soon  as  any  symptoms  of 
sepsis  are  apparent,  abdominal  section  is  to  be  performed. 
These  symptoms  are  chills,  remittent  temperature,  rapid  pulse. 
The  sac  is  to  be  opened,  the  decomposed  foetus  is  to  be  removed, 
and  the  opening  of  the  sac  is  to  be  stitched  to  the  abdominal 
wall.  Usually  the  placenta  will  have  become  freed  from  its 
attachments  and  may  be  removed  at  the  same  time.  Should  it 
be  adherent,  however,  it  is  preferable  to  allow  it  to  come  away 
in  fragments.  Free  drainage  should  be  maintained.  Usually 
this  operation  will  be  practically  extra-peritoneal. 

If  the  child  has  reached  full  term  and  is  alive,  a  very  in- 
teresting complication  calls  for  decision.  The  little  notoriety 
wdiich  one  gains  from  performing  a  brilliant  operation  should 
not  influence  the  conscientious  physician  for  a  moment.  jSTeither 
must  sentimental  notions  carry  the  least  weight  in  reaching  a 
conclusion.  The  question  to  be  decided  is  the  following: 
"Should  I  operate  and  possibly  save  the  life  of  the  child,  which 
at  best  will  stand  but  few  chances  of  surviving,  and  by  so  doing 
greatly  add  to  the  dangers  of  the  already-unfortunate  mother;  or 
should  I  delay  the  operation  and  thereby  permit  tlie  child  to  die 
and  the  placenta  to  lose  very  much  of  its  vascularity,  if,  indeed, 
not  all  of  it,  and  by  this  delay  very  much  enhance  the  chance 
of  recovery  of  the  woman  T'  To  those  who  will  look  at  this 
question  purely  from  the  stand-point  of  the  -s^lDman,  and  who 
will  consider,  as  they  ought,  the  ectopic  foetus  as  simply  a  para- 
site, the  choice  will  unquestionably  be  in  favor  of  delay.  No 
one  will  deny  the  legitimacy  or  the  imperative  necessity  of  re- 
sorting to  foeticide  in  the  non-controllable  vomiting  of  pregnancy, 
with  the  end  in  view  of  saving  the  woman.  The  belief  of  Tait, 
that  those  who  advocate  the  killing  of  the  child  in  developing 
extra-uterine  pregnancy  are  simply  "  abortion-mongers,"  is 
illogical,  and  must  be  looked  upon  as  one  of  those  statements 
which  are  made  in  haste  and  are  not  retracted  owing,  possibly, 
to  false  pride. 


ECTOPIC    GESTATION.  201 

After  the  child  is  dead  and  the  placental  circulation  has 
ceased,  operation  carries  far  less  danger  to  the  woman.  It  is 
contended  by  some  that  no  operation  should  be  performed  until 
symptoms  supervene,  but  nature's  tedious  methods  of  relief 
and  the  many  obvious  dangers  to  which  the  woman  must  be  ex- 
posed do  not  seem  to  justify  non-interference.  The  abdomen 
should  be  opened  as  soon  as  the  placental  circulation  has  ceased 
(and  this  is  certified  to  by  the  absence  of  placental  murmur), 
the  foetus  is  removed,  and  the  sac  is  stitched  to  the  abdominal 
wound.  If  the  placenta  is  detached  and  lying  free  it  should  be 
removed,  and  the  sac  is  drained  and  allowed  to  close  from  the 
bottom.  If  the  placenta  is  adherent,  no  attempt  should  be 
made  to  free  it,  for  it  will  come  away  gradually  through  the 
abdominal  opening.  Convalescence  is  hastened  if  a  vaginal 
opening  can  be  made  at  the  same  time  and  through-and- 
through  drainage  thus  established. 

Under  the  modern  method  of  treatment  we  have  outlined, 
ectopic  gestation  has  been  practically  robbed  of  its  terrors,  and 
the  almost  absolute  mortality  rate  of  the  past  has  been  con- 
verted into  the  almost  certain  recovery  rate  of  the  present. 
Once  again  is  the  value  of  election  in  obstetric  surgery  certified. 


INDEX. 


Abortifticients,  uselessiiess  of,  58 
Abortion,  artificial,  34 

in  absolute  pelvic  contraction,  3T 
in  case  of  haemorrhage,  39 
in  case  of  tumors,  38 
in  chorea,  36 

in  displacements  of  the  uterus, 
39 
operation  for  the  induction  of,  41, 
46 
in  pernicious  anaemia,  36 
in  pernicious  vomiting  of  preg- 
nancy, 35 
in   pulmonary  and  cardiac  dis- 
ease, 34 
in  renal  disease,  36 
Abscess,  mammary,  190 
pelvic,  188 

operation  for,  188 
Accouchement  force,  6Y 
Accoucheur,  asepsis  of,  2 
Anaemia,  pernicious,  artificial  abor- 
tion in,  36 
Anatomy  of  pelvis,  9 

of  symphysis  pubis,  121 
Antisepsis,  1 

definition  of,  2 
Arm,  prolapse  of,  method  of  rectify- 
ing, 107 
Arms,  methods  of  delivery  of.  111 
Asepsis,  1 

definition  of,  2 

of  accoucheur  and  attendants,  2 
of  genital  tract,  5 
of  hands  and  arms,  4 
of  instruments,  6 
of  ligatures  and  sutures,  7 
of  lying-in  woman,  5 
Axis-traction  forceps,  73,  74 
to  the  breech,  87 

Basiotribe,  Tarnier's,  154 
Beaudelocque,  diameter  of,  12 
Bipolar  version,  101 

method  of  performing,  103 


Bladder,  danger  of  injury  to,  in  sym- 
physiotomy, 123 

Braxton-Hicks  method  of  version, 
101 

Csesarean  section,  133 

abdominal  suture  after,  140 
absolute  indication,  132 
dilatation  of  cervix  after,  137 
election  in,  133 
indications,  133 
instruments  for,  134 
preparations  for,  135 
prognosis  of,  144 
relative  indication,  132 
statistical  data,  145 
suture  of  uterus  after,  138 
Catheter,  Fritsch-Bozeman,  42 
Cephalotribe,  application  of,  155 
disadvantages  of,  154 
Lusk's,  154 
Cephalotripsy,  operation  of,  153 
Cervix,  dilatation  of,  after  Csesarean 
section,  137 
lacerated,  immediate  repair  of,  163 
after-treatment,  167 
contra-indications,  164 
instruments  necessary,  164 
steps  of  operation,  165 
suture  material  for,  164 
manual  dilatation  of,  89,  102 
multiple  incision  of,  89,  105 
Chin,  arrested  at  symphysis,  extrac- 
tion of,  116 
Chorea,  artificial  abortion  in,  36 
Conjugate,  diagonal,  13 

true  (conjiigata  vera),  14 
Cranioclast,  Braun's,  149 

extraction  by,  150 
Craniotomy     of    the     after-coming 
head,  152 
of  the  before-coming  head,  150 
operation  of,  148 
Crotchet,  157 
Curette,  uterine,  41 

(203) 


204 


INDEX. 


Decapitation,  157 

deliveiy  of  bead  after,  159 
method  of  performance,  158 

Decollator,  Braun's,  158 

Diameters  of  fatal  head,  16 
of  pelvis,  external,  11 
internal  measnrements  of,  15 
pelvic,  increase  in,  by  S3-mph3'si- 

otom}',  122 
transverse  and  obliqne,  15 

Dilator,  steel-branched,  41 

Dilators,  hydrostatic,  66 

Dystocia,  obstetric,  9 

Eclampsia,  induction  of  labor  in  case 
of,  54 

podalic  version  in,  97 
Election,  value  of,  in  Caesarean  sec- 
tion, 133 

value  of,  in  s^-mphysiotomy,  121 
Electricity  as  a  means  of  inducing 

labor,  58 
Elytrotomy,  laparo-,  144 
Embryotomy,  146 

prognosis  of,  161 
Endometritis,  curetting  in,  182 

gauze  tampon  in,  184 

objections  to  douche  in,  181 

operation  for,  1 83 

post-operative  treatment  of,  185 

puerperal,  181 
Episiotomj',  83 
EAisceration,  155 

indications  for  and  dangers  of,  156 

Face  presentations,  low  forceps  in,  81 
Fistiilffi,  174 

after-treatment  of,  176 

operatiou  for  repair  of,  176 
Fcfital  head,  diameters  of,  16 
Foetus,  determination  of  eugaoement 
of,  51 

dimensions  of,  at  term,  16 

intra-uterine  measurement  of,  50 

length  of,  50 

manual  internal  rotation  of,  117 
in  case  of  occiput  posterior,  118 
Forceps,  72 

ansesthesia  for  extraction  by  the,  77 

application"  of  low,  81 
of  medium,  88 


Forceps,  compression  by  the,  75 

contra-iudications  to  the  use  of,  76 

direction  of  traction  in  low,  83 

Elliott's,  72 

forces  of  the,  74 

high,  91 

Hunter's,  73 

in  breech  presentations,  77 

indications  for  the,  76 

intra-uterine  dressing,  45 

introduction  of  left  blade  of,  79 

introduction  of  right  blade  of,  80 

Jewett's  axis-traction,  74 

leverage  of  the,  75 

locking  of,  80 

low,  in  face  presentations,  86 
in  occipito-posterior,  84,  85 

Lusk-Tarnier,  73 

medium,  dangers  of,  89 

ovum,  42 

position  for  the  application  of,  78 

prognosis  of,  92 

Reynolds's  tniction  rods  for,  75 

rotation  by  the,  75 

to  after-coming  head,  116 

to  breech,  87 
Funis,  prolapse  of,  version  in,  97 

Galbiati  knife,  objections  to,  129 
Gestation,  ectopic,  193 

broad  ligament,  rupture  of,  195 

treatment  of,  196 
development  of,  to  term,  199 

treatment,  200 
diagnosis  of,  193 

at  time  of  rupture,  194 
before  rupture,  194 
intra-peritoneal  rupture,  194 

primary,  195 
operation  for  primary  rupture,  197 
terminations  of,  193 
treatment  after  fretal  death,  201 
treatment  of  broad-ligament  rup- 
ture, 199 
Glycerin,  injections  of,  for  inducing 
labor,  60 

Hffimorrhage,  artificial   abortion   in 
case  of,  39 
as  a  complication  of  symph3'siot- 
omy,  129 


INDEX. 


205 


Hsemorrhage,  induction  of  labor  in 

case  of,  53 
Hands,  asepsis  of,  4 
Head,  after-coming,  forceps  to,  116 
arrested  at  brim,  extraction  in  case 

of,  115 
delivery  of,  after  decapitation,  159 
foetal,  arrested  at  symphysis  116 

compressibility  of,  51 
on  perineum,  method  of  delivery 
of,  83 
Heart  disease,  artificial  abortion  in, 

84 
Hook,  blunt,  15*7 
Hunter's  low  forceps,  73 
Hysterectomy,  laparo-,  141 
after-treatment,  144 
indications,  142 
technique,  142 

Incision,  multiple,  of  cervix,  89,  105 
Incubator,  69 
Instruments,  asepsis  of,  6 

Jewett's  axis-traction  forceps,  74 
Justo-major  pelvis,  18 
Justo-minor  pelvis,  19 

Kidney  disease,  artificial  abortion  in, 

36 
Knife,  Galbiati,  124 
Krause's  method  for  inducing  labor, 

61 
Kyphosis,  24 

Labor,  premature,  induction  of,  47 
in  case  of  eclampsia,  54 
in  case  of  deformed  pelves,  48 
in  case  of  haemorrhage,  53 
method  for,  58 
prognosis  of,  68 
Laparo-elytrotomy     (vide     Elytrot- 

omy) 
Laparo-hysterectoni}^    (vide    Hyste- 
rectomy) 
Ligament,    subpubic,    necessity    of 
cutting,  in  symph^^siotomy, 
126 
Ligiitures,  asepsis  of,  7 
Lusk-Tarnier  forceps,  73 


Mastitis,  glandular,  191 
puerperal,  1 90 
subglandular,  192 
Membranes,    puncture    of,    for     in- 
ducing labor,  58 
Mento-posterior  position,  symph3^si- 

otomy.iu,  127 
Metritis,  abdominal  section  in  case 
of,  185 
extension  of  sepsis  causing,  184 
puerperal,  181 

jSTurse,  asepsis  of,  2 

Occipito-posterior    position,   forceps 
in,  84 
manual  rotation  in,  118 
symphysiotomy  in,  127 

Oophoritis,  septic,  186 

Osteomalacia,  28 

Pelves,  abnormal,  17 

contracted,  symphysiotomy  in,  122 

deformed,  b}^  tumors,  31 
induction  of  labor  in,  48 
Pelvic  version,  elective,  96 
Pelvimeters,  11 
Pelvimetry,  11 

digital,  13 
Pelvis,  anatomy  of,  9 

circumference  of,  16 

contraction  of,  artificial  abortion 
in,  37 

diameters  of,  increase  in,  by  S3'm- 
pliysiotomy,  122 

external  diameters  of,  11 

flat,  racliitic,  23 

flattened,  20 

funnel-shaped,  28 

internal  diameters  of,  13 

justo-major,  18 

justo-minor,  19 

kvphotic,  24 

Naegele,  30 

oblique-ovate,  30 

osteomalacic,  28 

rachitic,  21 

rachitic-scoliotic,  26 

scoliotic,  25 

spondylolisthetic,  27 

transversely  contracted,  24 


206 


INDEX. 


Perforator,  Blot's,  148 

scissors,  149 
Perineorrhaphy,  after-treatment,  1T3 
contra-iudicatioiis,  168 
for  complete  rupture,  172 
for  partial  rupture,  170 
Hegar's  method  of,  170 
immediate,  167 
instruments  requisite  for,  169 
method  of  performing,  169 
suture  material  for,  171 
Perineum,  central  laceration  of,  173 
laceration  of,  determination  of,  168 
A'arieties  of  laceration  of,  168 
Peritoneum,  methods  of  infection  of, 

187 
Peritonitis,   differentiation    of  local 
from  general,  187 
intra-peritoneal,  encapsulated,  189 

operation  for,  190 
local,  188 

operation  for,  188 
puerperal,  186 
Placenta  prsevia,  53 

bipolar  version  in,  102 
Porro     operation     (vide    H^sterec- 

tom}-) 
Pregnancy,  extra-uterine  (vide  Gres- 
tation,  ectopic) 
pernicious  vomiting  of,  35 
Puerpei'ium,  surger}^  of,  163 
Pulmonary  disease,  artificial  abortion 
in,  34 

Quinine  to  promote  contractions,  90 

Rachitis,  21 

Rej-nolds's  traction  rods,  75 

Roberts's  pelvis,  24 

Rotation,  manual,  of  foetus,  117 

Salpingitis,  septic,  186 
Scoliosis,  25 
Specula,  Simon's,  175 
Speculum,  Edebohl's,  43 
Spondylolisthesis,  27 
Spondylotomy,  157 
Sponges,  dangers  of  using,  7 
Suture,  uterine,  138 
Sutures,  asepsis  of,  7 


S3'mphysiotomy,  120 

after-treatment  of.  128 

amount  of  gain  in  diameters  by, 
122 

anatomical  considerations,  121 

complications  of,  128 

delivery  after,  126 

factors  controlling,  123 

Galbiati  knife  for,  124 

indications,  122 

instruments  essential  for,  124 

prognosis  of,  130 

repair  of  wound  after,  127 

statistical  data,  130 

structures  involved  in,  122 

technique  of,  124 

subcutaneous  method,  125 

ultimate  results  from,  129 
Sj'mphj^sis  pubis,  effect  of  operation 
at,  129 

mobility  at,  128 

Tenaculum,  cervical,  43 
Trephine,  Braun's  148 

Martin's,  149 
Tumors,  deforming  the  pelvis,  31 

pelvic,  artificial  abortion  in,  37 
Twins,  locked,  161 

Urethra,  danger  of  injury  to,  in  syva- 

physiotomy,  123 
Uterus,  displacements,  artificial  abor- 
tion in,  39 
management    of,   after    Caesar ean 

section,  136 
rupture  of,  177 

abdominal  section  in,  179 

annular,  181 
prognosis  of,  179 
suture  of,  after  Csesarean  section, 

138 
tamponade  in,  180 
treatment  of,  178 
varieties  of,  177 

Yagina,  asepsis  of,  5 

hand  in,  for  p.urpose  of  examina- 
tion, 99 

tamponing,  for  inducing  labor,  59 
Yaselin,  dangers  in  using,  6  .    . 


INDEX. 


207 


"Version,  93 

bipolar,  in  case  of  placenta  prsevia. 
102 

Braxtoii-Hicks  method,  101 

by  external  manipulations,  101 

cephalic,  94 

combined  method  of,  101 

internal,  105 

extraction  after,  110 
extraction  of  head,  112 
insertion  of  hand  in,  106 
rotation  of  foetus  b3^  94 
seizure  of  foot  in,  lOT 


Version,    liberation    of    arm    after, 

111 
nomenclature  of,  94 
pelvic,  94 

objections  to,  100 
performance  of  cephalic,  95 
podalic,  96 

contra-indications  of,  97 

indications  for,  97 

preparations  for,  99 
prognosis  of,  119 
varieties  of,  94 


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Price,   in  United  States  and  Canada,   SS1.75,  net;  Great  Britain,  10s.; 
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International  System  of  Electro=Therapeutics. 

For  Students,  General  Practitioners,  and  Specialists.  Chief  Editor,  Horatio 
R.  BiGELOW,  M.D.,  Fellow  of  the  American  Electro-Therapeutic  Association ; 
Member  of  the  Philadelphia  Obstetrical  Society  ;  Member  of  the  Societe  Fran- 
gaise  d'Electro-Therapie  ;  Auth(n-  of  "Gynaecological  Electro-Therapeutics,"  and 
"Familiar  Talks  on  Electricity  and  Batteries,"  etc.  Assisted  by  thirty-eight  eminent 
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many  fine  Engravings.     1160  pages.    Royal  Octavo. 

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IVINS — Diseases  of  the  Nose  and  Throat. 

A  Text-Book  for  Students  and   Practitioners.     By  Horace   F.  Ivins,  M.D., 
Lecturer  on  Laryngology  and  Otology,  Hahnemann  Medical  College  of  Phila.,  etc. 
Royal  Octavo.      507  pages.      With  129   Illustrations,  chiefly  original,  including  18 
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*  JOAL — On  Respiration  in  Singing. 

For  Specialists,  Singers,  Teachers,  Public  Speakers,  etc.  By  Dr.  Joal  (Mont 
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KEATING— Record=Book  of  Medical  Examinations  for  Life= 
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Designed  by  John  M.  Keating,  M.D.  This  record-bo'ok  is  small,  but  com- 
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KEATING  and    EDWARDS— Diseases  of    the    Heart    and 
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With  an  Appendix  entitled  "Clinical  Studies  on  the  Pulse  in  Childhood."  By 
JOHN  M.  Keating,  M.D.,  Philadelphia,  and  William  A.  Edwards,  M.D.,  Phila- 
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KRAFFT=EBINQ— A  Text=Book  on  Insanity. 

For  the  Use  of  Students  and  Practitioners.  By  Dr.  R.  von  Krafft-Ebing. 
Authorized  translation  of  the  Fifth  German  Edition  by  Charles  Gilbert  Chad- 
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LIEBIQ  and  ROHE — Electricity  in  Medicine  and  Surgery. 

By  G.  A.  LiEBiG,  Jr.,  Ph.D.,  Assistant  in  Electricity,  Johns  Hopkins  Uni- 
versity, etc. ;  and  George  H.  Rohe,  M.D.,  Professor  of  Obstetrics  and  Hygiene, 
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riANTON — A  Syllabus  of  Lectures  on  Human  Embryology. 

An  Introduction  to  the  Study  of  Obstetrics  and  Gynaecology,  with  a  Glossary 
of  Embryologi'cal  Terms.  By  Walter  Porter  Manton,  M.D.,  Lecturer  on  Ob- 
stetrics in  Detroit  College  of  Medicine ;  Fellow  of  the  Royal  Microscopical  Society, 
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MASSEY — Electricity  in  the  Diseases  of  Women. 

AVitli  Special  Reference  to  the  Application  of  Strong  Currents.  By  G.  Betton 
Massey,  M.D.,  Late  Electro-Therapeutist  to  the  Philadelphia  Orthopaidic  Hospital 
and  Infirmary  for  Nervous  Diseases,  etc.  Second  Edition.  Revised  and  Enlarged. 
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niCHENER— Hand=Book  of  Eclampsia. 

Or,  Notes  and  Cases  of  Puerperal  Convulsions.  By  E.  Michener,  M.D.  ; 
J.  H.  Stubbs,  M.D.  ;  R.  B.  Ewing,  M.D.  ;  B.  THOMPSON,  M.D. ;  S.  Stebbins, 
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nONTQOMERY— Practical  Gynecology. 

By  E.  E.  Montgomery,  A.M.,  M.D.,  Professor  of  Clinical  Gynaecology  in  the 
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Thoroughly  Illustrated.    In  Preparation. 

*  MOO  RE— rieteorology . 

By  J.  W.  Moore,  B.A.,  M.Ch.,  University  of  Dublin  ;  Fellow  and  Registrar  of 
the  Royal  College  of  Physicians  of  Ireland,  etc.  Part  I.  Physical  Properties  of  the 
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from  its  Beginning  to  the  Present  Day,  specially  contributed  by  Prof.  W.  M. 
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*MYQIND— Deaf^Mutism. 

By  HoLGER  Mygind,  M.D.,  of  Copenhagen.     The  only  authorized  English 

Edition.    Edited  by  R.  Norris  Wolfenden,  M.D.Cantab.,  of  London.    Comprising 

Introduction,  Etiology  and  Pathogenesis,  Morbid  Anatomy,  Symptoms  and  Sequelae, 

Diagnosis,  Prognosis,  and  Treatment.    Crown  Octavo.    About  300  pages.    Cloth. 

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NISSEN — A   Manual   of    Instruction   for    Giving    Swedish 
flovement  and  Massage  Treatment. 

By  Prof.  Hartvig  Nissen,  late  Instructor  in  Physical  Culture  and  Gym- 
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Physicians'     All-Requisite     Time*-,    and     Labor«     Saving 
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Being  a  Ledger  and  AccoTint-Book  for  Physicians'  LTse,  meeting  all  the  Re- 
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reduces  the  labor  of  keeping  physicians'  accounts  more  than  one-half,  and  at  the 
same  time  secures  the  greatest  degree  of  accuracj'. 

Prices :  No.  1,  300  pages  for  900  Accounts  per  Year,  size  10  x  12,  bound 
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Physicians'  Interpreter. 

In  Four  Languages,  English,  French,  German,  and  Italian.  Specially  arranged 
for  diagnosis  by  M.  VON  V.  The  plan  of  the  book  is  a  systematic  arrangement  of 
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PURDY— Diabetes. 

Its  Cause,  Symptoms,  and  Treatment.  By  Chas.  W.  Purdy,  M.D.,  Honorary 
Fellow  of  the  Royal  College  of  Physicians  and  Surgeons  of  Kingston  ;  Author  of 
"Bright's  Disease  and  Allied  Affections  of  the  Kidneys"  ;  Member  of  the  Associa- 
tion of  American  Physiciaiis ;  Member  of  the  American  Medical  Association,  etc., 
etc.    With  Clinical  Illustrations.    12mo.    184  pages.    Extra  Cloth. 

Price,  in  United  States  and  Canada,  SI. 25,  net;  Great  Britain,  6s.  6d. ; 
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PURDY — Practical  Uranalysis  and  Urinary  Diagnosis. 

A  Manual  for  the  Use  of  Physicians  and  Students.     By  Chas.  W.  Purdy, 
M.D.,  Author  of  "  Diabetes  :  its  Cause,  Symptoms,  and  Treatment";  Member  of  the 
Association  of  American  Physicians,  etc.,  etc.    With  numerous  Illustrations,  includ- 
ing several  Colored  Plates.    Crown  Octavo.    About  350  pages.    Extra  Cloth. 
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REnONDINO— History  of  Circumcision. 

Fiom  the  Earliest  Times  to  the  Present.  Moral  and  Physical  Reasons  for  its 
Performance  ;  with  a  History  of  Eunuchism,  Hermaphrodism,  etc.,  and  of  the 
Different  Operations  Practiced  upon  the  Prepuce.  By  P.  C.  Remondino,  M.D., 
Member  of  the  American  Medical  Association,  of  the  American  Public  Health 
Association  ;  Vice-President  of  California  State  Medical  Society,  etc.  12mo.  346 
pages.  Extra  Cloth.  Illustrated  with  two  line  full-page  Wood-Engravings,  showing 
the  two  principal  modes  of  Circumcision  in  ancient  times. 

Price,  in  United  States  and  Canada,  ®1.25,  net;  Great  Britain,  6s.  6d. ; 
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France,  3  fr.  60. 

REflONDINO— The  flediterranean  Shores  of  America. 

Southern  California :  its  Climatic,  Physical,  and  Meteorological  Conditions. 
By  P.  C.  Remondino,  M.D.  Royal  Octavo.  175  pages.  With  45  appropriate  Illus- 
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*ROBINSON  and  CRIBB— The  Law  and  Chemistry  Relating 
to  Food. 

A  Manual  for  the  Use  of  persons  practically  interested  in  the  Administration 
of  the  Law  relating  to  the  Adulteration  and  Unsoundness  of  Food  and  Drugs.  By  H. 
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Strand  District,  etc.    Crown  Octavo.    About  SOU  pages. 

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ROME— Text-Book  of  Hygiene. 

A  Comprehensive  Treatise  on  the  Principles  and  Practice  of  Preventive  Medi- 
cine from  an  American  Stand-point.  By  George  H.  Rohe,  M.D.,  Professor  of  Ob- 
stetrics and  Hygiene  in  the  College  of  Physicians  and  Surgeons,  Baltimore  ;  Member 
of  the  American  Public  Health  Association,  etc.  Third  Edition,  carefully 
revised  and  enlarged,  with  many  Illustrations  and  valuable  Tables.  Royal  Octavo. 
Over  450  pages.    Extra  Cloth. 

Price,  in  United  States  and  Canada,  S3. 00,  net ;  Great  Britain,  17s.  6d. ; 
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ROHE — A  Practical  flanual  of  Diseases  of  the  Skin. 

By  George  H.  Rohe,  M.D.,  assisted  by  J.  Williams  Lord,  A.B.,  M.D.,  Lect- 
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Baltimore,  etc.    12mo.    Over  300  pages.    Extra  Cloth. 

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SAJOUS — Hay  Fever  and  its  Successful  Treatment, 

By  Superficial  Organic  Alteration  of  the  Nasal  Mucous  Mem- 
brane.     By  Charles  E.  Sajous,  M.D.,  Chief  Editor  "  Annual  of  the  Universal 
Medical  Sciences"  ;  formerly  Lecturer  on  Rhinology  and  Laryngology  in  the  Jeffer- 
son Medical  College,  etc.    With  13  Engravings  on  Wood.    12mo.    Extra  Cloth. 
Price,  in  United  States  and  Canada,  SI. 00,  net ;  Great  Britain,  6s. ; 
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*SCHUSTER— When  is  flarriage  Permissible  after  Syphilis? 

By  Dr.  Schuster,  of  Aix-la-Ciiapelle.  Translated  from  the  German  by  C. 
Renner,  M.D.,  London.    8vo.    32  pages.    Price,  35  cents  net,  or  1  shilling. 

SENN — Principles  of  Surgery. 

By  N.  Senn,  M.D.,  Ph.D.,  Professor  of  Principles  of  Surgery  and  Surgical 
Pathology  in  Rush  Medical  College,  Chicago,   111.  ;   Professor  of   Surgery  in  the 
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SENN — Tuberculosis  of  the  Bones  and  Joints. 

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of  them  colored. 

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VOUGHT — Chapter  on  Cholera  for  Lay  Readers. 

History,  Symptoms,  Prevention,  and  Treatment  of  the  Disease.  By  Walter 
VotTGHT,  Pli.B.,  M.D.,  late  Medical  Director  and  Physician-in-Charge  of  the  Fire 
Island  Quarantine  fetation,  Port  of  New  York ;  Fellow  of  the  Xew  York  Academy  of 
Medicine,  etc.    Illustrated.    12mo.    106  pages.    Flexible  Cloth. 

Price,  in  United  States  and  Canada,  75  cents,  net ;  Great  Britain,  48. ; 
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WITHERSTINE— International  Pocket  Medical  Formulary. 

Arranged  Therapeutically.  By  C.  Su3i>'ER  Witheesti^'E,  A.M.,  M.D.,  Vis- 
iting Physician  of  the  Home  for  the  Aged,  Germautown,  Philadelphia ;  late  House 
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from  several  hundred  well-known  authorities.  With  an  Appendix  containing  a  Po- 
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275  printed  pages,  besides  extra  blank  leaves  for  new  formulss.  Elegantly  printed, 
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YOUNG — Synopsis  of  Human  Anatomy. 

Being  a  Complete  Compend  of  Anatomy,  including  the  Anatomj'  of  the  Viscera, 
and  Numerous  Tables.  Bj'  Ja3Ies  K.  Youxg,  M.D.,  Instructor  in  Orthopaedic  Sur- 
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Illustrated  with  76  Wood-Engravings.    320  pages.    12mo.    Extra  Cloth. 

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Annual  of  the  Universal  Medical  Sciences. 

A  Yearly  Report  of  the  Progress  of  the  General  Sanitary  Sciences  Throughout 
the  World.  Edited  by  Charles  E.  Sajotjs,  M.D.,  formerly  Lecturer  on  Laryn- 
gology and  Rhinology  in  Jeiferson  Medical  College,  Philadelphia,  etc.,  and  Seventy 
Associate  Editors,  assisted  by  over  Two  Hundred  Corresponding  Editors  and  Col- 
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with  Chromo-Lithographs,  Engravings.  Maps.  Charts,  and  Diagrams.  Being  intended 
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Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 


ADAMS— History  of  the  Life  of  D.  Hayes  Agnew,  fl.D.,  LL.D. 

By  J.  Howe  Adams,  M.D.  A  fascinating  life-history  of  one  of  the  woiid's 
greatest  surgeons.  Royal  Octavo.  376  pages.  Handsomely  printed,  with  Portraits 
and  other  Illustrations. 

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KRAFFT=EBINQ— Psychopathia  Sexualis. 

With  Especial  Reference  to  Contrary  Sexual  Instiuct :  A  Medico-Legal  Study 
of  Sexual  Insanity.  By  De.  R.  voit  Kkafft-Ebing,  Professor  of  Psychiatry  and 
Neurology,  University  of  Vienna.  Authorized  Translation  of  the  Seventh  Enlarged 
and  Revised  German  Edition,  by  Charles  Gilbert  Chaddock,  M.D.,  Professor 
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RANNEY — Lectures  on  Nervous  Diseases. 

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BROSE  L.  Ranney,  A.M.,  M.D.,  formerly  Professor  of  the  Anatomy  and  Physiology 
of  the  Nervous  System  in  the  New  York  Post-Graduate  Medical  School  and  Hos- 
pital, etc.  ;  Author  of  "The  Applied  Anatomy  of  the  Nervous  System,"  "Practical 
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SAJOUS— Lectures  on  the  Diseases  of  the  Nose  and  Throat. 

Delivered  at  the  Jefferson  Medical  College,  Philadelphia.  By  Charles  E. 
Sajous,  M.D.,  formerly  Lecturer  on  Rhinology  and  Laryngology  in  Jefferson  Medi- 
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SCHRENCK=N0TZ1NQ— Suggestive   Therapeutics    in    Psy= 
chopathia  Sexualis. 

By  Dr.  A.  von  Schrenck-Notzixg,  of  Munich.  Authorized  Translation  of 
the  Last  Enlarged  and  Revised  German  Edition,  by  Charles  Gilbert  Chaddock, 
M.D.,  Professor  of  Nervous  and  Mental  Diseases,  Marion-Sims  College  of  Medicine, 
St.  Louis,  etc.  An  invaluable  supplementary  volume  to  Dr.  R.  vok  Krafft- 
Ebing's  masterly  treatise  on  '•Psychopathia  Sexualis"  (also  translated  by  Dr. 
Chaddock).  A  kind  of  hand-book  of  the  treatment  of  Sexual  Pathology  upon 
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Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 


5TANT0N — Practical  and  Scientific  Physiognomy. 

Or,  How  to  Read  Faces.  By  Mary  Olmsted  Stantox.  Copiously  Illus- 
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^Journal  of  Laryngology,  Rhinology,  and  Otology. 

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